Ship To Address:
Alpine Telecom
9945 Mesa Rd.
Chipita Park, CO 80809

Customer:________________________________________
Address:_________________________________________
City:_____________________________________________
State:________________________
Zip code: ______________
Phone:_______________________

Telephone(s) to be repaired and refurbished:
 

Quantity	Part Number	Color

Billing Information:
Credit Card Number:_______________________
Name on credit card:_______________________
Expiration date:______________
Billing zip code:______________
Key code number on back of the card (3 digits):______
Cost $69.00x___________plus shipping & handling: ______
We ship UPS ground, unless otherwise you need air freight!

All repairs carry a 1-year warranty.