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

Name: _______________________________________________________________

Address: _____________________________________________________________

City, State, ZIP: ________________________________________________________

Phone: ________________________ E-Mail: ________________________________

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

OPTIONS:

                ________ 4.1 Line Outputs ($15)              
                ________  BT-2 Bluetooth Module w/ Voice Command, Voice Assist ($170)
                ________  USB-2 USB/MP3/AAC Adapter ($100)
                ________  BTU-2 Bluetooth AND USB ($220)
      ________ HPC-1 Power booster ($100) (Required for vehicles without 12v negative ground available)
               
Additional information/instructions: _________________________________________________________
NOTE:  Special instructions regarding conversion MUST be approved in advance!
 
PAYMENT INFORMATION:  (Required prior to service)
 
________  Check Enclosed
________  VISA, MC, DISC, AMEX:  __________________________________
Expiration:  ________    CVV Code:  ______
________  Submitted via phone call
 
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For Office Use Only:

Date Received: __________________   Condition: :________________________________

 Model # ___________________  Notes: __________________________________________________