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North/South America Customer

Part I. Customer Information (* indicates required fields)

     
RMA Request Date:  
Customer Name: *  
Customer Account Number:  
Shipping Address: *
(No PO Box)		  
Address Line 2:  
City: *  
State or Province: *  
Zip Code: *  
Country: *  
Tel Number: *  
Fax Number:  
Email Address: *  
Reenter Email Address: *  
     

Part II. Product / RMA Detail (* indicates required fields)

     
RMA Item #1  
Unigen Part Number: *
UG
-
Customer Part Number:    
Unigen Mfg Part #:    
Quantity: *  
Invoice/Sales Order #: *  
Invoice Date: *  
Unit Price:  
Sales Name/Sales Company Name:  
RMA Type *  
Return Reason *  
     
   
     
Customer Comments:    
     

Part III. Type of Defect

   
Please specify how we will ship the item to you.
   
Shipping Method: *
   
To ensure your RMA request is processed promptly, please ensure that all information is complete and correct. Improper information will delay the processing of your RMA request.
   
     
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