Radio Work Form

Radio Owner Information

First Name (required)

Last Name (required)

Address (required)

City (required)

State/Province (required)

Zip/Postal Code (required)

Country (if not USA) (required)

Cell Phone (required)

Home Phone (required)

Email (required)

Radio Information

Year (required)

Make (required)

Voltage (if other than 12v Neg.) (required)

Type of work you want done on radio (choose one):

Restoration (restore to original condition)Conversion (convert to digital AM/FM with jacks for iPod / Satellite Radio)

Please check if you are interested in:

SpeakersBlue Tooth ($180.00 option)USB Port ($100.00 option)Combination Blue Tooth and USB Port ($250.00)Line Outs (for subwoofer and/or additional external amplifier, $25.00 option)

Comments (required)

Shipping Directions:

Along with this work form, enclose a check or money order for $200 as a deposit on conversions only
Remove knobs and keep them at home
Wrap radio well – please do not use inflatable air pillows
Mail radio with this completed Work Form to:
Retro Radio Restoration
5524 Ridge Road
Elizabethtown, PA 17022

Please check if you want to be contacted when your radio is received and logged in.

Thank you for your business. Call us at 717-367-1428 if you have any questions.