Radio Stereo Conversion

D&M Restoration

STEREO CONVERSION Information 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: 12volt / 6volt              Polarity: Positive Ground / Negative ground

Other OPTIONS: (check options to add)
________  4.1 Line Outputs 
_
_______  BT-2 Bluetooth Module w/ Voice Command, Voice Assist
________  USB-2 USB/MP3/AAC Adapter
________  BTU-2 Bluetooth AND USB
________  HPC-1 Power booster (Required for vehicles without 12v negative ground available) 
 
Additional information/instructions: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________
NOTE: Special instructions regarding conversion MUST be approved in advance!
 
PAYMENT INFORMATION: 
(We will call you with an estimate before work starts – We Require A Credit Card Number upfront before beginning work)