Your Company Name          

First Name Last Name

Address Street        

Address Suite/Apt   

City                             

State                          

Country                     

Email Address          

Confirm Email            

Telephone                  

EL Display being sent in for repair:

Planar EL Display EL series      Model:

Finlux /Planar MD series          Model:

Sharp EL Display LJ series       Model:

What make and model machine do you have? (This is important for us because you may qualify for a replacement display from Capetronics Inc if your display cannot be repaired)

Describe your problem you are having with your display as best you can.