Warranty Parts Request Form
A separate form is required for each part request.
Name
*
First Name
Last Name
Today's Date:
*
-
Month
-
Day
Year
Date
Account Number- wholesale companies we work with:
Ex: AB123 (If you do not have an account number, please leave blank.)
Your Telephone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Email Address:
*
example@example.com
Proof of purchase (S0#, PO# or INV#):
Model Number:
*
For an item under warranty please upload your proof of purchase as either a .jpg or .pdf file/ without proof this request will be a purchase:
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Manufacture Date (stamped on law label under seat cushion):
*
-
Month
-
Day
Year
Date
CA Registry# (stamped on label under seat cushion)
*
Please upload pictures of the Law Label which must also include the Manufacture Date. Please make sure the file is either a .jpg or .pdf:
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Please provide a brief description of the malfunction:
*
Please Please provide a photo of the defective part. Photos are required for all cushion replacement requests. If you are missing a part, please circle it on the assembly sheet and upload a picture. Please upload either a .jpg or .pdf:
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If the product arrived damaged, please provide pictures of the box from all angles, pictures of the law label with manufacture date, and pictures of the damaged products. Please upload either a .jpg or .pdf:
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Please provide the package tracking number or upload a photo below as a .jpg or .pdf:
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Part Requested:
*
Gas Lift
Base
Seat Cushion
Mechanism
Caster
Back Cushion
Other
If other, please describe:
Quantity Requested:
*
Ship to address for replacement part(s):
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CSR:
Picture submitted to factory?
Yes
No
Replacement SO#
Date:
-
Month
-
Day
Year
Date
Notes:
Submit
Should be Empty: