RA Request Form

Customer Information:

Name:

Address:

Address Line 2:

City:

State/Province:

Postal Code:

Email address:

Telephone:

Fax:

Order Information: (Please provide one of the following)

Order Number: (abcd1234)

Invoice Number: (12345)

Items List (Please list the items from this order you would like to return)

Reason for Return:

(If Other - Please explain below.)

Other reason:

Item Condition (If you select no on any of the following please explain below)
Are all items in their original, factory sealed packaging?
Are all items un-used?
Are all items in original packaging with all component parts, literature and warranty cards included?
Are all items in re-sellable condition?
Were all items delivered to you within the past 30 days?

Please explain:
Comments (Please provide any comments or special requests regarding this return request.)