Name: _____________________________________________________________________________________________
Shipping Address: ___________________________________________________________________________________
City, State, ZIP: _____________________________________________________________________________________
Phone: _________________________________ E-Mail: ____________________________________________________
Year/Make/Model of Vehicle: ______________________________________________ Voltage: ______ Polarity: _______
OPTIONS:
________ BTU Module, includes Bluetooth and USB MP3/AAC Adapter for Flash Drive($220) ________ BT Bluetooth by itself ($170) ________ USB Adapter by itself ($100) ________ 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 for 6 volt and/or positive ground electrical systems ($100) 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 -- remember we can't begin until we hear from you! ________ Credit Information included (See Below) * * * * * * * * * *Date Received: ________________________ Condition: :____________________________________________________________
Model # ______________________________ Notes: _______________________________________________________________
CREDIT CARD INFORMATION:
Visa, Mastercard, Discover, American Express
This is designed to print on a separate page so it can be shredded afterwards.
Card Number: _________________________________________________________________________________
Expiration: __________________________________ CVV Code: _______________________
Billing Address StreetNumber (If different from above): _______________________ ZIP Code: ________________