Name  _________________________________

Address   _____________________________________

                _____________________________________

Telephone  ________________________

Photo ID ___     (attach copy of Driver’s License)

Salesman  _______________________        Sales Inv #  _____________

Instrument  ___________________________       Case:  hard/ soft/ none

Ser #  _______________________________        Credit _____________

Condition __________________________________________________

Serviced by ________________________

Work done _________________________________________________

___________________________________________________________

Photo ______    On Web ______                                Price at __________

Comments __________________________________________________

___________________________________________________________

___________________________________________________________

I hereby attest that I am the sole owner (or owner’s agent) for the above listed property. Furthermore, I certify

that I have the legal right to sell said property and that it is free from all liens and encumbrances.

Signature of Seller ________________________________________ (date)

Signature of Buyer ________________________________________ (date)