Print this form
to send in with unit to :
BC Electronics
2346 BRISTOL-OXFORD VALLEY RD
LEVITTOWN, PA 19057-1305
Phone:   215-547-7600       

Please complete and print clearly to help speed up your repair.

Name___________________________________________________
Address_________________________________________________
City______________________________State______Zip__________


Remember that UPS requires packages to go to a physical address (not PO Box) and
someone should be there to receive it.  (We currently ship by UPS only)

Return shipping address if different than above:___________________________________________
_____________________________________________________________________________________

EMAIL ADDRESS : ___________________________________
Home Phone (____)____________________
Work Phone  (____)____________________

Cell Phone or Pager (____)__________________

For Original Equipment Car Product please provide the Year, Make & Model of the vehicle:
_________________________________________________________
Anti-theft code needed for anti-theft radios only:
Usually found in glove box (looks like a credit card). Code________________(3-5 digit number)

Problem with unit_____________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

You are responsible for the packaging when shipping to us.
You can insure your equipment for just a few dollars, but the best insurance is to be sure it is packaged correctly.
Insurance won't pay if not correctly packaged.   PACKAGING GUIDELINES

THIS IS YOUR AGREEMENT FOR THE MINIMUM LABOR / DIAGNOSTIC CHARGE AND PAYMENT.
I am aware there is a non-refundable minimum labor charge of $63.50 for a diagnosis / estimate
on each unit that I send in for repair.
This Fee does not include return shipping. Return shipping charge will be based upon current
UPS pricing.

Please circle one:    ESTIMATE FIRST      or      OK TO REPAIR UP TO $_________

Signed _______________________ Print Name as on card: _____________________

Billing Address & Zipcode ( if different than above )______________________________________

Circle Credit Card Type:    MasterCard    -    Visa    -   Discover    -    Amex

Card # __________________________ Exp ________ Security Code*_________

* The Security Code is 3 digit number after last 4 numbers on the signature area on back of Visa, MasterCard,
or Discover. Amex prints 4 digits on the front of the card above and to the right of the account number.

Enclosed is my check / money order for $________ (personal checks - allow 14 days to clear)