FMR-2 STEREO CONVERSION ORDER FORM
Please fill out this form and include it with your radio.
           

Name: _____________________________________________________________________________________________

Shipping Address: ___________________________________________________________________________________

City, State, ZIP: _____________________________________________________________________________________

Phone: _________________________________ E-Mail: ____________________________________________________

Year/Make/Model of Vehicle: ______________________________________________    Voltage: ______ Polarity: _______

OPTIONS:                  

                ________  BT Bluetooth Module w/ Voice Command ($170)
                ________  USB MP3/AAC Adapter for Flash Drive ($100)
                ________  BTU Module, includes BOTH Bluetooth AND USB ($220)
                ________  HD Radio  (North America) OR  ________  DAB Digital (Europe) ($120)
 
                ________  CM-1 Courtesy Module, stereo remains on until door is opened ($75)
                ________  Line Level Outputs 4.1 for external amps ($15)
                ________  Tube Emulation Mode, set comes on gradually like a tube set ($20)
                ________   Auto Volume Control (For 1957 Thunderbird w/ original ignition) ($20) 
                ________   VOX Input Mode, Automatic Input Switching (No Cost Option)
 
      ________ HPC-1 Power booster ($100) (Required for vehicles without 12v negative ground available)
               
Additional information/instructions: _________________________________________________________
 
______________________________________________________________________________________________
 
 
PAYMENT INFORMATION:  (Required prior to service)
 
                ________  Check Enclosed (PLEASE check with us first to verify the exact amount!)
                ________  Credit Information submitted via phone or other means
                ________  Credit Information included (See Below)
 
*    *    *    *    *    *    *    *    *    *

For Office Use Only:

Date Received: ________________________   Condition: :____________________________________________________________

 Model # ______________________________  Notes: _______________________________________________________________

 

 

 

 

 

CREDIT CARD INFORMATION:

Visa, Mastercard, Discover, American Express

 

Card Number:  _________________________________________________________________________________

Expiration:  __________________________________    CVV Code:  _______________________

Billing Address StreetNumber (If different from above):  _______________________    ZIP Code:  ________________