GO TECHNOLOGIES PTY LTD

A.C.N. 120 274 615

A.B.N. 36 516 736 533
PO BOX 9129, Scoresby, Vic. 3179 Australia
Telephone (03) 9237 0800 Facsimile: (03) 9237 0808

Email: codes@go-tech.com.au

SECURITY CODE REQUEST FOR EUROVOX UNIT

PLEASE E-MAIL, MAIL OR FAX THIS FORM FULLY COMPLETED WITH

CORRECT PAYMENT AND

PHOTOCOPY OF DRIVERS LICENCE OR

REGISTRATION PAPERS.
Cost of Security Code: $22.00 Inc GST
YOUR REQUEST WILL BE PROCESSED BY THE NEXT BUSINESS DAY.
If you have been given a code/s previously please state the code number:
_________________________________
OWNERS NAME: . ........................................................................................... TEL.No: ................................................
ADDRESS: ........................................................................................................ POST CODE:........................................
RADIO MODEL No: ....................................... .... RADIO/DVD

SERIAL No*: ...................................................

TYPE AND MODEL OF VEHICLE: ........................................................ REGISTRATION: ............................................

* UNIT MAY NEED TO BE REMOVED TO GET SERIAL NUMBER CANNOT PROCESS WITHOUT THIS NUMBER *
CARD REQUESTANT (i.e Company,Dealer): ....................................................... CONTACT NAME: ............................
EMAIL ADDRESS:.
ADDRESS: .................................................................................................................. POST CODE: ..............................
TEL. NO: ........................................................ FAX NO: ................................................. ORDER No: ............................
CREDIT CARD DETAILS

EFT PAYMENTS: ANZ BSB: 013414

ACCOUNT: 4940-22292

NAME: .................................................................................................................................................................................................
PLEASE DEBIT MY:

MasterCard

VISA

AMEX

EXP.DATE:

CARD NUMBER: ___ ___ ___ ___

___ ___ ___ ___
___ ___ ___
Please note that if you are paying by AMEX YOU WILL BE CHARGED AN EXTRA 2.2%

___

___________________

___

___

___

___

I HEREBY GIVE AUTHORISATION FOR GO TECHNOLOGIES PTY LTD TO DEBIT MY ACCOUNT. SIGNED: ......................................

NOTE: AN INCOMPLETE REQUEST RECEIVED WILL NOT BE PROCESSED.

NO REFUND IS AVAILABLE AFTER CODE IS GIVEN.
SERIAL NUMBER SHOULD BE TAKEN FROM THE UNIT ITSELF.
UNIT MAY NOT ACCEPT ITS RIGHT CODE IF IT HAS AN INTERNAL FAULT.
ALL INVOICES AND CODE CARDS WILL BE POSTED TO THE CARD REQUESTANT

DECLARATION BY APPLICANT
I HEREBY CONFIRM THAT TO THE BEST OF MY KNOWLEDGE THE ABOVE INFORMATION IS TRUE AND CORRECT.

OWNERS SIGNATURE: ...................................................................................................................................................