Customer Name or Shop
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
SHIPPING INFORMATION (No PO Boxes)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Place of Purchase
Date of Purchase
-
Month
-
Day
Year
Type of Light or Part Number
*
Invoice Number
Serial Number on Light Cord
Full Front Image of Light(s)
*
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Copy of Invoice
*
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Submit
Should be Empty: