In-home Service Dispatch

At Your Service Since 1984

Name : *
Address : *
City : *
Zip Code : *
Home phone : *
Cell phone :
Make & model : *
Is the back of the tv is accesible? *	Yes No
Is the TV hanging on the wall or inside a cabinet? *	Yes No
Date of purchase : *
Place of purchase/Dealer *
Contract / Reference # :
Describe in detail the problem with your unit : *
Notes/Warranty info/special request :