ADKINS TV

Name: _____________________ Phone# _______________

Address: __________________________________________

Components Brought In: _____________________________________

Model#____________________________________________________

Issuses:
____________________________________________________________
____________________________________________________________

$35 check out fee. Applied to repair cost. If repair cost

of TV is more than TV can be replaced for, $35 can be
waived by leaving TV for parts.

Customer signature:_________________________
Date:_______________________________________

Adkins TV is not responsible for items left on the

premises for over 30 days. All items left over 30
days may be made available for resale to cover any
and all repair/storage costs.

For Technician Use Only:

Work Done
___________________________________________________________

Replaced Hardware
___________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Notes :
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