SOUTHERN ELECTRONICS RADIO REPAIR FORM rev 7.0 copyright 2001 Southern Electronics Inc.
Please print out and complete fully to help speed your repair. Thank you for choosing Southern
SALUTATION:_______ NAME____________________________ DATE _____/_____/____
RETURN ADDRESS FOR REPAIR TO BE SHIPPED TO: (Location should have someone to receive)
Apartment or Suite_______ Street Address___________________________________________
City_________________________________ State _________ Zip Code ____________________
PHONE NUMBERS, Include area code Daytime ____________ Evenings______________
EMAIL ADDRESS____________________________ @_______________________
PAYMENT METHOD. PLEASE CHECK ONE: 

[  ]   CREDIT CARD, PAYMENT. PLease complete below. No charges made until ready to ship.For Security Credit Card Information Is Not Kept In A Computerized Data Base. You may also call us toll free at 1-866-263-5263 with this information.

  • CARD NUMBER ___________    ___________    ___________    ___________
  • EXPIRATION DATE: Month:____________    Year________
  • CARD TYPE: MasterCard[ ]     Visa[ ]     Discover[ ]     American Express[ ]
  • FULL NAME, On Card ______________________________ SIGNATURE_______________________
  • ADDRESS WHERE CREDIT CARD BILL IS RECEIVED

  • Apartment or Suite __________ Street Address______________________________________
    City____________________________________ State _________ ZIP CODE ________________
[  ]   CHECK INCLUDED, This will delay process 10 days.Checks are cashed when received. 
    Refunds for overpayment will be sent separately by US mail
[  ]   COD.Add $15.00 to estimates for UPS fee. Cannot ship COD to PO Box
[  ]   PRICE QUOTE. Please email quote[ ]    &nbspPlease call with quote [ ]
PROBLEM WITH UNITPlease Check All Boxes That Problem Occurs. The more information we have the better we can troubleshoot.
  • What Function?: AM [ ]    FM [ ]    Cassette [ ]    CD [ ]    Display [ ]    Amplifier [ ]    Other [ ] 
  • What Volume Setting? Normal [ ]     High [ ]    Low Volume [ ] 
  • Engine Noise Problems. When Does The Problem Occur? Ignition In Accessory Position [ ]    Ignition On Run, But Engine Off [ ]  &nbspEngine Running? [ ]  &nbspWith Head Lights On? [ ] 

  • When _____ Is Turned On [ ]  &nbspWhen Stopped [ ]    When Driving? [ ]  &nbspHitting Bumps [ ] 
  • Check Which Speakers Are Affected? All [ ]    Left Front Bottom [ ]    Left Front Top [ ] 

  • Right Front Bottom [ ]    Right Front Top [  ]        Left Rear [ ]  &nbspRight Rear[ ] 
  • Does The Problem Occur? Always [ ]    Often [ ]  &nbspRarely [ ]    When Hot [ ]    When Cold [ ] 

  • More details___________________________________________________________________
    MAKE OF CAR_____________________ Model____________________ Year____________________

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