DATE:  __________     CORE FOR ___________________________________

                    CUSTOMER NAME:  ________________________________

                    PHONE #:__________________

                    EMAIL Address:  _________________________________

                    Form of Payment: ( ) eBay     ( ) Paypal     ( ) Other ______________________

                    Your Vehicle:  YEAR _____  MAKE ____________  MODEL _____________

                    What seems to be the problem with your unit?:_________________________________                   

                                                                                                                                              

                    Would you like your CD(s) mailed back to you:  Yes ( )        No ( )
                   

                    Select your unit type:     Six CD ( )       Single CD ( )      DVD Player ( )

                    PLEASE NOTE: We do not payout on units that have water damage, motherboard/electrical issues,
                    AM/FM reception, sound output, or power issues. If we receive your radio and it has one of these                         issues, we will assume you want us to recycle it. By signing below, you are confirming that you                     understand the above statement.

                    Signature: ____________________________________________    Date: _________