Form Example 1 - Encore Electronics

16483 OLD VALLY BLVD
LA PUENTE CA 91744
Tel: 626-336-4567 Fax: 626-336-2345
Optional Extended Warranty Request Form
DISCLAIMER
The complete “Extended Warranty Contract” for Encore Electronics, Inc., products supersedes all other warranties
and representations, whether written or oral, except as expressly set forth on this additional warranty statement.
This extended warranty contract is available to consumers only, excluding any third party retailer or distributor.
Encore Electronics, Inc. Warrants that the product (s) will be replaced or repaired, and, if Encore Electronics, Inc.
is unable to replaced or repaired the product, will provide an upgrade for a similar product with the same
functionality, and it will be sent to consumer at not extra cost.
Encore Electronics, Inc. will warrant the product (s), set forth below after all necessary information and fees have
been completed and will begin on the date set on your invoice. Please complete all the information and return the
forms to us via fax at: 626-336-2345
Select one of the additional warranty terms below
Qty Unit price Amount
1 Year of Optional Extended Warranty _____ $19.99 $___________
2 Years of Optional Extended Warranty _____ $24.99 $___________
Total Amount $___________
Model Number: _________________________ Serial Number: _______________________
Model Number: _________________________ Serial Number: _______________________
Personal Information
Date: _______________________
First name: _______________________ Last name: _______________________________
Tel number: _________________________ E-mail: ________________________________
Address: ____________________________ City: ________________________________
Zip Code: ___________________________ Country: ________________________________
REV 042811.1

Credit Card Information
16483 OLD VALLY BLVD
LA PUENTE CA 91744
Tel: 626-336-4567 Fax: 626-336-2345
Optional Extended Warranty Request Form
Authorization for credit card charges
Card Type: ________________________ Card Security Code: ______________________
Card Number: ______________________ Card Expiration Date: _____________________
Billing Information
Name on Card: __________________________________ Last Name: ___________________
Company Name (If applicable: ___________________________________________________
Address: _____________________________________________________________________
City: _________________________ State: ______________ Country: ___________________
Zip Code: ____________ Card holder E-mail: _____________________________________
Charges to be billed to the above credit card Amount $ ________________________________
Authorization
I hereby authorize Encore Electronics, Inc. to make the above charges according to the designated
frequencies listed above, and I (we) understand that all information entered on this form will be kept
strictly confidential by Encore Electronics, Inc. In the event of any unauthorized charges made on the
above credit card, I hereby agree to indemnify and hold blameless on Encore Electronics, Inc. for any an
all such charges, claims and liability related hereto. This authorization will remain in effect for the
payments listed above, and, or, until I (We) give written notice to terminate or revise it.
Signature: _________________________ Position Title: __________________________
Print Name: ________________ ___________ Date: _________________________________
For Encore Electronics, Inc. Use only!
Info verified by: _____________________
Date: ______________________________
REV 042811.1