* For "defective" RA requests, please state or describe the nature of the defect.

Customer Name		Purchase Order No
Order Email		Order Date mm/dd/yyyy
Phone

Itemcode	Description	Quantity	Price
			$
			$
			$
Shipping	2nd Day 3 Day Ground	Tax	$
	Other	Total	$

Return Reason	Defective Dissatisfied Repair Other
Return Request	Exchange Refund Store Credit Other
Return Description and Customer Comments
Security Code