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1. Please Provide Your Order Information:
Items marked * are required.

Name: *
Company Name: *
Invoice No.: *
Order Date: *
Date of Receipt: *
E-mail Address: *
Fax Number:
Phone Number: *


2. Please List Damaged Items:
Use individual quantities (not pack quantities).
Line # Quantity Item # Description Color/Other
1.
2.
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4.
5.


3. This merchandise was: *

Refused Accepted


4. Description of the Damage: *



5. Please this form to us OR print and Fax it to us at
866 740 0147.

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