Customer Details

Customer Name       

House No/Name       

Street/Road Name   

Town                      

City                       

Post Code              

Contact Name                 

Contact Tel Number

Mobile Number       

Vehicle Details

Make of Vehicle       Model of Vehicle     Year of Vehicle   Reg Number 

Is the vehicle (Cost will vary for 24V)   12v   24v Not Sure

Does the Vehicle have built in Sat Nav ? Yes  No

Phone Details

Make of Phone       Model of Phone          Is the Phone Bluetooth    Yes   No

Extras (cost will vary)

Do you want sound through car radio   Yes   No                    Do you want a phone holder for dashboard      Yes  No

Do you want no holes drilled special bracket  Yes No

Any Other Comments

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Clear Comms Use Only

Car Kit Required       Sot Lead Req   Yes   No   Ref    Holder Req   Yes   No   Ref

Mounting Bracket Req   Yes   No   Ref    Voltage Dropper Req   Yes   No    Antenna Req   Yes   No

Boot Ext Lead Req  Yes   No