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Name
*
First
Last
Company Name
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Home Phone Number
*
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Cell Phone Number
*
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Work Phone Number
*
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Email
*
Make/Brand
*
Model Number
*
Serial Number
*
Choose One
*
TV is under Manufacturer warranty
TV is under Extended or Insurance warranty
No warranty
Not sure
Dealer Name (If TV is under Manufacturer warranty)
*
Date of Purchase (If TV is under Manufacturer warranty)
*
Select One
*
TV is on a stand -or- not wall mounted
TV is wall mounted - I CAN help to dismount
TV is wall mounted - I CAN NOT help to dismount
Trouble/Complaint
*