Date:____________ Customer Name:__________________________________________________________

Home Phone _____________________ WK Phone ___________________ EMAIL_____________________

Shipping Address: Home or business. If business, MUST have Business Name.

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Type of Machine:___________________________ Referred by:_____________________________________

Do You have a working backup machine?_____________

Description of problem/Service to be performed: __________________________________________________

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Payment Info: Services must be paid in full before machine can be shipped back to you.
How will you be paying? Credit Card - (circle one) Visa, MasterCard, Discover, A/E

Card #__________________________________Exp. Date_______________ Check #___________________

Date you would like machine back in your hands:__________________________________________________

Do you have a Fedex account that you would like billed? Acct.#______________________________________

Do you use paper/ribbon?___________________                Do you use your numeral bar?__________________

Do You use Notemarks on Paper?__________        Is it ok to erase Ram? (Mira's manditory)_________________

Would you like a Steno Styles Custom Restoration? ___________(view examples on website, call for details)
                                                                                                                  
Special Requests:_________________________________________________________________________

Please list the name and address of the Ministry or Charity that will be receiving the $10.00 donation check. Or write "your ministry" if you would like the donation to go to our local Ministry.