Name :   Date :
Address :   Customer # :
City : State: Zip:   Email :
Phone :   Invoice # :

Items being returned:

Qty. Item Number Description Return Reason
Reason for Return:
Mark with a "X"
Not what was ordered
Not needed once received
Defective *see below
Damaged in Shipment **see below
Missing parts
Other- Please explain
Action Requested:
Exchange for items below:
Comments:
Qty. Item Number Description Price
Payment for any additional amount:
Mark with a "X"
Credit Card # (last 4 digits)
Check/Money Order
Gift Certificate/Other
Credit back: (note: We refund using orginal payment method only)
Mark with a "X"
Credit back my credit card (last 4 digits)
Send a refund check
Send a replacement
Other
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