R&M Warranty Request Form

WARRANTY REQUEST FORM:

Date:*
Requested By:*
Company Name:*
Address 1:*
Address 2:
City:*
State/Province:*
ZIP/Postal Code:*
Country:*
Phone Number:*
Fax Number:*
E-mail Address:*
R&M Order Number:*
Customer P.O. Number:
Model No. / Serial No.:*
1. Quantity:*	Part Number:*	Reason for Request (be specific):*
2. Quantity:	Part Number:	Reason for Request (be specific):
3. Quantity:	Part Number:	Reason for Request (be specific):
4. Quantity:	Part Number:	Reason for Return Request (be specific):
5. Quantity:	Part Number:	Reason for Request (be specific):
REPLACEMENT PARTS SHIPPING INFORMATION
SHIP VIA (Choose One):	Standard freight = paid by R&M	Expedited freight = paid by others

SHIP TO: ( IF DIFFERENT FROM PURCHASER )		Expedited Freight Shipper Information Fill in this information if you have chosen Expedited freight
Company Name:
Address 1:
Address 2:
City:
State/Province:
ZIP/Postal Code:
Country:
Phone Number:
Fax Number:
E-mail Address:

	Note: Warranty freight paid by R&M will be UPS Ground or equivalent. Expedited freight is the responsibility of others - please check the box that pertains to the shipping method - and if using your account number it can be written in the box. All original items replaced under warranty MUST be returned unless otherwise stated on the warranty acknowledgment form. A complete warranty policy information is available in the Owner's manual or at www.rmhoist.com. Please include NCR# on outside of package to be returned. SHIPPER IS RESPONSIBLE FOR RETURN PACKAGING.
	* denotes required field
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