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Untitled Document

WARRANTY CLAIM FORM

6 Pine Hill Dr

Carlisle PA 17013

Ph: 717/243 2535 Fx: 717

Submitted: 

Date                

FAX # 717 243 7270       

***(Must be filled out COMPLETELY and LEGIBLY)***

PLEASE CHECK APPLICATION
(   )CREDIT                                    PROOF OF PURCHASE ORDER #:  (                                 )        (   )REPLACEMENT

CLAIM MUST BE FILED WITHIN 30 DAYS FROM DATE OF SERVICE
DISTRIBUTOR

Company Phone #:
Street Fax:
City   Date: 
State, Zip   Claim Review By: 

Ship Replacement Parts to:

Company   Phone #: 
Street   Fax: 
City, State, Zip    

*End User Unformation*

*Servicer*

Customer's name:  Customer's name: 
Address  Address 
City  City 
State, Zip  State, Zip 
Phone:  Phone: 

**Equipment**

MODEL NUMBER:
SERIAL #
Installation Date:  Date Service Completed: 

Explanation of Failure

Use other side if necessary

*Was problem caused by freight damage?   Yes No

*Did you file a freight claim?   Yes No

I certify I have properly serviced this system.

;
Servicer Signature

Parts Information

Part Number Description Qty

Handling Request for Returned Part

If purchased through a distributor, return claim form & part to distributor.

Approved By: Date:
Quietside Boilers