Test

DATE
[text text-517 "mm" cols:10 rows:5]/
Today's Date (If you are using Internet Explorer or Firefox, please input the date as (YYYY-MM-DD).

Company Name

Company Address

Your Name (as it appears on the card)

Your Email

Best Phone Number to Reach You (ex. 555-555-5555)

Credit Card Type (We accept Visa, Mastercard and American Express)
VisaMastercardAmerican Express
Last Four Digits of Credit Card

Credit Card Expiration Date
(If you are using Internet Explorer or Firefox, please input the date as (YYYY-MM-DD).

I have read and understand, that if the problem is NOT A PART FAILURE, MANUFACTURER DEFECT or if the MANUFACTURER DETERMINES THAT THE REPAIR IS NOT COVERED UNDER WARRANTY, payment for the service call will be my responsibility and will be due upon completion of the service and I agree to pay for the service rendered per the terms above. If I do not have cash or a company check available or if I am not at the service location when the work is completed, I then authorize Jay-Hill Repairs to charge my credit card on file (last four digits listed above).

Customer Signature: