Warranty Claim Form

First Name

Last Name

Phone

Company Name

Billing Address

Billing Country

Billing State

Billing Province

Billing City

Billing Zip/Postal Code

Shipping Country

Shipping State

Shipping Province

Shipping Address

Shipping City

Shipping Zip/Postal Code

Shipping Address Type

Attachment Model Number

Attachment Type

Attachment Name

Attachment Serial Number

Purchase Invoice Date

Failure Date

Host Machine Make/Model

Purchase Invoice Number

Dealer Name

Dealer City

Your Dealer Contact

Description of Failure

Upload Photos of Failure

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I accept warranty policies