NEC NP200 - Application Sheet for TravelCare Service Program

Date: / /
TO: NEC or NEC's Authorized Service Station:
FM:
(Company & Name with signature)
P-l/ ,
Country,
product purchased :
User's Company Name :
User's Company Address :
Phone No., Fax No. :
User's Name :
User's Address :
Phone No., Fax No. :
Local Contact office :
Local Contact office Address :
Phone No., Fax No. :
User's Model Name :
Date of Purchase :
Serial No. on cabinet :
Problem of units per User :
Required Service : (1) Repair and Return (2) Loan unit
Requested period of Loan unit :
Payment method : (1) Credit Card (2) Travelers Cheque (3) Cash
In Case of Credit Card :
Card No. w/Valid Date :
Application Sheet for TravelCare Service Program
Dear Sir (s),
I would like to apply your TravelCare Service Program based on attached registration and qualification sheet and agree with
your following conditions, and also the Service fee will be charged to my credit card account, if I don't return the Loan units
within the specified period, also confirm following information is correct. Regards.
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