SERVICE ORDER FORM NEW - GM Gauge Repair

SERVICE ORDER FORM GM GAUGE REPAIR – 931 Liberty St. La Crosse, WI 54603 (608)-304-0155 [email protected]

PLEASE PRINT CLEARLY AND INCLUDE WITH YOUR SHIPMENT Name: _______________________________________________________________ Shipping Address: ______________________________________________________ City: _______________________________ State: ______ Zip: ___________________ Email: ______________________________________Phone:____________________ Year: _________ Make: __________________Model:__________________________

PLEASE CHECK SYMPTOMS OR FAILURES THAT APPLY __ Gauge Failure: ___________________________________ __ Odometer Display: Mileage____________ __Gear Indicator (PRNDL) Display __Backlighting Dim or Dead __Cluster Completely Dead (no gauges, backlighting, PRNDL) __Cluster comes ON/OFF intermittently __Other, please explain__________________________________________________

SERVICE NEEDED __Single Gauge Repair: ____________________________ __Complete Rebuild: (2003-2006 GM only) __Gear/Odometer Display: (1997-2002 Models) __Dodge/Chrysler Cluster Repair

PAYMENT Amount Quoted: $_________ __Check or Money Order (Payable to Todd Haines) __PayPal (attach copy of receipt) PayPal ID: [email protected] __Credit Card (VISA, MasterCard, Discover) Card #:____________________________ Expiration______ CV#:_____ Name on Card: ___________________________

HOW DID YOU HEAR ABOUT US? Internet__

Magazine Ad__

Referral: _______________________________________________________________ Other: ________________________________________________________________

CUSTOM GAUGES AND LED’S LED’s - Color’s Available: __White __Blue __Red __Green Vinyl Gauge Face – Color_______________ (check one->) LED Edition__ Regular Edition__ __Stainless Steel Edition __Aqua Stainless Edition __Whitetail White Vinyl Lens Cover – __OEM New __OEM Used __Camo __Chrome Rings __Carbon Fiber Needles – Color’s Available: __Chrome __Carbon __Red __Camo __Blue __Clear