Title Mr Mrs Miss Other    

First Name          Surname         

House Number         Flat Number         Building Name

Street Name     Town County

                        Postcode                   

                                                                    Contact Numbers

Home Telephone         Mobile Telephone

Work Telephone         Fax                      

Email Address   * Required

Unit Type  Select Type Audio CRT Television DVD DVD Recorder DVD and HDD Recorder HDD Recorder LCD TV Microwave Plasma TV Projection TV Video         Model Number         Serial Number

Unit Manufacture  Select Make Aiwa Alba Bang and Olufsen Bose Bush Daewoo Denon Ferguson Finlux Goldstar Goodmans Grundig Hinari Hitachi JVC Kenwood LG Loewe Marantz Mitsubishi Nad Orion Pace Panasonic Philips Pioneer Roberts Sanyo Samsung Sharp Sony Thomson Toshiba Wharfdale Other     Other

Repair Type  Select Charge Chargable Insurance warrenty         Date of Purchase (we are required to see proof of purchase prior to commencing repair)

Dealer Purchased From

Insurance Company         Policy Number         Referral Number

Fault Description

Preferred day for service call            Any Monday Tuesday Wednsday Thursday Friday Saturday   Calls are normally made between 9:30 & 17:30

Submitting this request does not confirm a call. we will contact you to confirm any appointment