Ship to:   Delta  Audio   7054 N Clark St.   Chicago, IL 60626	Date
Company  Name	Shure Dealer Number
Address	Please note: No shipments made to P O boxes
City	State     Zip
Contact  Name
Phone	Ext.   Cell
Fax
Email
Brand name
Type of unit
Items included
Detailed problem description
Notes
Return Shipping    and Insurance	Basic return shipping via UPS or USPS ground is included in your labor cost. If you want to have your equipment insured, please enter the amount of insurance you want in the box below and we will add it to your bill.

Note your payment preference (optional):  (check one)   Visa     MC			How did you hear about us?
Account Number:			Delta Audio Web Page    Shure Brothers       Facebook
Cardholder's Name:			Yelp      Google search      Twitter
Expiration Date:		CVC	Other      Thank you
No checks or money orders.

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