Radio Stereo Conversion Form

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: ______
Polarity: _______

Other OPTIONS:


________ 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 – We Require A Credit Card Number
upfront before beginning work) 
 
—————————————————————————————————————-


For Office Use Only:

Date
Received: __________________   Condition:
:________________________________

Model #
___________________
Notes: __________________________________________________