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Return/Repair Authorization Request

* 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
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   

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