WARRANTY/SERVICE RETURN FORM
Thank you for taking the time to fill out your return form.
Your Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Product
*
Please Select
Ultradot Gen 1 25mm
Ultradot Gen 1 30mm
Ultradot Gen 2 25mm
Ultradot Gen 2 30mm
Ultradot 4
Ultradot 6
Matchdot
Matchdot II
HD Micro
Ultradot L/T
Ultradot Pan AV
Other
Other Product Name
Product Serial Number
If Applicable
Purchased From
*
Date of Purchase
*
-
Month
-
Day
Year
Date
Return Date
-
Month
-
Day
Year
When return shipment is sent
Upload a Copy of Your Receipt
Problem Description
*
For best and quick service, please describe here the problem or fault as detailed as possible.
Check This Box to Accept the Service Cost if not Covered by Warranty
Signature
Please send your product to following address:
Ultradot Warranty Service
PO Box 212
Andover NJ 07821
Notification Received Date
-
Month
-
Day
Year
Date
Returned Product Received Date
-
Month
-
Day
Year
Date
Shipping Cost
Proof of Purchase Received
Yes
No
Issue With Sight
Repair Results
Internal Notes
Completion Date
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Month
-
Day
Year
Date
Shipping Date
-
Month
-
Day
Year
Date
Status
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Received
In Progress
Completed
Notified Customer
Shipped
Japan
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