Cobra Technologies Customer Information Update Form

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Customer Information Update Form

In order to make sure the records in our computer are up to date, we would appreciate it, if you could take some time and fill in or update the following information.

If you would prefer to fax the form to us you may download a Microsoft Word Document here and fax it to 770-435-0402

Items marked with a * are required fields.

Customer Number
*Company or City/Municipality

*Street Address
*City
*State
*Zip/Postal code
*Contact Person who can authorize repair work and issue PO numbers

*Phone
Cell Phone
Fax
*Email Address
Secondary Contact Person

Do you require purchase order numbers?

Yes
No

*What color video cable do you use?

Green
Black
Blue
Light Green
Orange
Red
Other

*What type of termination do you use?

12 Pin Swivel
8 Pin Cobra
5X4 Pin
8 Pin Cues
Other

*Do you want your return shipments insured?

Yes
No
Camera Serial Numbers
Crawler Serial Numbers
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Thank you for your cooperation and have a great day!