Philips Priority Service CUSTOM CONTRACT ORDER FORM

Fill out the Order Form and mail it with a check (payable to ON SITE LTD) and copy of retail invoice to: ON SITE LTD, 551 Roosevelt Rd., #151, Glen Ellyn IL, 60137.

*All shaded fields are required in order to process contracts

Dealer: ON SITE LTD	Dealer ID Number: IL020298002	Salesperson Number: Phil Pollard
Dealer Address: 551 Roosevelt Rd., #151	City: Glen Ellyn	State/Province, Zip Code & Country: IL, 60137

EQUIPMENT OWNER

Last Name:	First Name:	MI
Customer Service Address:
City:	State/Province:	Zip Code & Country:
Home Phone:	Work Phone:	E-mail Address:
Customer Billing/Mailing Address:
City:	State/Province:	Zip Code & Country:
Date Product(s) Purchased:	Contract Date:

Extended Service Plan

Covered Products

Term (Mos)

Description

Product Make

Product Model No

Serial Number

Product Retail $

On-Site or Carry-In

Mfg. Parts WNTY

Mfg. Labor WNTY

Prod. Code

Item Code/SKU

Contract Retail $

Ex: (60)

(Plasma TV)

(Philips)

(HS21-048)

(5896D12345)

(5198.94)

(On-Site)

(24 mos)

(36 mos)

(LTJ42)

TOTAL ORDER:

The Customer signing below acknowledges that he/she has read, understands and agrees to this entire application including the Terms and Conditions on reverse side. Customer should receive certificate within 4-6 weeks. If not received, contact your installing dealer.

Phil Pollard

Customer Signature Date Dealer Signature Date

REV.2/15/02