Return Materials Authorization Request

Date of Request: *

Customer Name: *

Contact Name: *

Telephone #: *

Email Address: *

Billing Address: *

Shipping Address is the Same as Billing Address:

Shipping Address:

Return Shipping Method:

Collect Shipping Acct#:

Purchase Order #: *

Terms (Please Choose One): * Net 30Credit Card Payment

Reason For Return (Please Choose One): * OtherEvaluationCredit

If returning for credit, original purchase order information must be provided and restocking fee may apply

RETURNED ITEM #1:

Part #: *

Quantity: *

Item Description: *

RETURNED ITEM #2:

Part #:

Quantity:

Item Description:

RETURNED ITEM #3:

Part #:

Quantity:

Item Description:

Description of Request or Problem: (Please do not use the word “Defective”, Include as much detail as possible, specifically as it relates to a failure condition) *

TERMS: A lab charge of $50.00 will be assessed to the RMA and no credit will be issued if our inspection and testing determines that the returned product(s) are not defective and the reason for failure is from improper installation technique, improper handling, abused, dropped, improper treatment, or misused. This RMA is voided and no product analysis will take place without your approved and binding signature below.

Type in the Name of Person Who is Filling Out This Form: *

Today's Date: *

By clicking "Yes" you agree to the Terms: Yes I Agree *