Instructions!

Please complete this form and
click on the send button at the bottom.

*Required Fields

* Name:
*Address:
*City:
*State:
*Zip:
* Phone #:
Fax #:
* Email:
Product Name:	Amana Dishwasher Amana Dryer Amana Range Amana Refrigerator Amana Washer Ge Dishwasher Ge Dryer Ge Range Ge Refrigerator Ge Washer Hotpoint Dishwasher Hotpoint Dryer Hotpoint Range Hotpoint Refrigerator Hotpoint Washer Jenn-Air Dishwasher Jenn-Air Range Jenn-Air Refrigerator Kitchenaid Dishwasher Kitchenaid Dryer Kitchenaid Range Kitchenaid Refrigerator Kitchenaid Washer Maytag Dishwasher Maytag Dryer Maytag Range Maytag Refrigerator Maytag Washer Roper Dishwasher Roper Dryer Roper Range Roper Refrigerator Roper Washer Whirlpool Dishwasher Whirlpool Dryer Whirlpool Range Whirlpool Refrigerator Whirlpool Washer
*Model:
*Serial #:
*Months	36 Month 60 Month
Original Invoice #:	(If you have it)
Card type	Visa Discover Mastercard
Card Number
Exp Date
Card ID No.
	You may also send payment to the above address Along with a copy of this form Note: If you have more than one appliance you want contracts for, please email mailbox22@parkwayappliance.com All Service Contract prices as followed: All appliance prices (Any Brand) 36 Month $89.95 60 Month $119.95 Stack Washer/Dryer Price $109.95 $139.95 Air Conditioners over 18,000 btu $99.95 $129.95 Contracts have a 90 days grace period   Any appliance package of 2 appliances receives a 5% discount. Any appliance package of 3 appliances or more receives a 10% discount. Thank You!