Company
Contact First Name
Contact Last Name
Email
Phone
Return Shipping Address
City
State / Province Outside the U.S. and Canada AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NF NH NJ NM NS NT NU NV NY OH OK ON OR PA PE QC RI SC SD SK TN TX UT VA VT WA WI WV WY YT
Zip Code
Original Invoice No.
Item Part No.
Item Case No. (If Applicable)
Quantity
Serial No.
Description of Problem
Are you sending the item for? Repair Warranty Evaluation Credit
Is the unit locked up? (Yes/No)
Are you sending the motor? (Yes/No/Not Applicable)
In what application is the unit used?
What is the operating voltage?
What is the operating vacuum/pressure level?
How many months has the unit been in service?
Name of Person Submitting Request:
Date
First & Last Name:
Comments