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Note : This form is not for return of product you will not be credited. For returns please contact 877-255-0004.
Date :
Name / Company
(if applicable)		 :
P.O. (if applicable) :
Telephone number
(where we can reach you during business hours)		 :
Address :
City :
State :
Country :
Email :
Reason for Replacement :
Purchase location & date: :
  Qty Wattage UPC
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Customer service will call you within 14 days of receiving your request to verify and confirm your replacement.