|
Contact Information |
|
salutation
and name |
|
e.g., Mr. John
Smith |
|
address 1
|
|
|
| address 2
|
|
|
|
city, state,
zip/postal code |
|
|
|
telephone
number (day) |
|
|
| telephone number
(evening) |
|
|
| fax number
|
|
|
|
email
address |
|
|
|
Replacement Part |
|
product
|
|
e.g., MCS-303D
|
|
color
|
|
|
|
missing/damaged part |
|
e.g., top
drawer, casters |
|
quantity |
|
|
|
retailer
|
|
|
|
location of
retailer (city/state) |
|
include both city and
state |
|
reason for
replacement |
|
please choose one
|
| If other, please enter
here |
|
|
|
Replacement Part |
| product |
|
e.g., MCS-303D
|
| color |
|
|
| missing/damaged part
|
|
e.g., top
drawer, casters |
|
quantity |
|
|
|
retailer |
|
|
| location of retailer
(city/state) |
|
include both city and
state |
| reason for
replacement
|
|
please choose one
|
| If other, please enter
here |
|
|
