3739 Osage Street
Stow, Ohio 44224-4262
BUSINESS NAME: __________________________________________________________
ADDRESS: _________________________________________________________________
CITY: ______________________________________________
STATE: ____________________________________________
ZIP CODE: _________________________PHONE:_________________________________
___ Computer Portrait System___ IBM PC ___Compaq PC ___ (Other) PC ___ Laptop
___ Video Printer___Laser Printer___Inkjet Printer___ Wax Thermal Printer ___Dot Matrix
___ Scanner ___Monitor___ Mug Press___Handheld Remote ___Keyboard___ Mouse
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***NOTE: For VIDEO PRINTERS send extra video paper and Ink cartridge for testing purposes.
DATE NEEDED BY: ____________________________
DATE IN: ___________________________DATE OUT: ___________________________
MODEL #:____________________________SERIAL #:____________________________