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REMOTE REPAIR ORDER FORM
Name___________________________________________________
Address________________________________________________
City___________________________________________________
Postcode_______________________________________________
Email__________________________________________________
Phone__________________________________________________
Payment Method by Cheque P.O. made payable to AnyRemote
Paypal? Payment Date Please_____________
Visa Mastercard American-Express Maestro
Card Number__________ ___________ ___________ _________
Expiry Date______________ Valid From______________
Issue Number_____________
Security Code____________
Repair Information
REMOTE BRAND______________REMOTE NUMBER________________
MODEL NUMBER______________
PROBLEM WITH REMOTE
___________________________________________________________________________________
___________________________________________________________________________________
SPECIAL INSTRUCTIONS
__________________________________________________________________________________
___________________________________________________________________________________
Standard Remotes £12.50 [ ] Special Remotes £18.00 [ ]
Special Remotes consist of multiple circuit boards or slides. Not sure then send £18.00 and we will refund the difference.
Price includes return post and packing. For your own protection and piece of mind we recommend either sending by recorded
delivery or obtaining a certificate of posting.
TOTAL AMOUNT £___________ ENCLOSED
Post completed form and Remote to:
Remote Repair Service
Field View House
Green Lane
Hemingby
Lincolnshire
LN9 5QH
or
CALL 01507 578773
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