Order-Form

AutomotiveModules.com Updated: OCTOBER 2024 (734) 228-8679

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MidwestTecKmart.com

Thunderbird 2002-05 Front Electronic Module Rebuild expert & Ford Trucks Gem. 1995 -2019

Work Order, (repair Authorization)

To print this form : just highlight the white portion of this page then click print ,then hand write the answers with a pen and place it in the package with your Module that you send in for repair. Please do not forget to sign this form.

Name....................................................Service Center Name(if you are a company).....................................................

Address.................................................................................City..............................State.......................Zip..................

Phone # (..........) ............ ................. Email or Cell Phone. ........... ................... ............................. .................................................

I am sending Module called.........................................................which Determined by qualified Tech:needs repair.

The part Number is............................................................... The Mileage is .............................................

Year...........Make..............Model........................ Vin ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... ..... .... .... .... .....

Please write what is original customer Complaint ? in Simple Truth ,Non Technical Terms.

Did you replace any Part but it did not fix the problem ? or any prior attempt to repair this module?..........................

Diagnostic Codes if available #....................Code Full description............................................................................................

please be advised ,providing DTC Codes and their full definition is very helpful for our repair provide them here if

you have them.

Any Malfunction Indicator Lights is on? ........................ .......................... .......................

Name of the person who paid on line ............................................Payer Signature............................ Date..........................

Notice: We ONLY ship your Item back to the address that credit card company or PayPal gives us.

You can add one or more new addresses in your PayPal or Credit card account, then at the time of check out, just check the box for the address you wish to be shipped to.