MDL WARRANTY CLAIM FORM

Who is filling out this form? (We'd like to contact you!)*

PrefixFirst NameLast Name

Company Name*

Which company are the wearers from?

Email (Our first contact will be via email.)*

Confirmation Emailexample@example.com

Phone Number (We might need to call you during the process.)*

Please enter a valid phone number.

Invoice Number*

Please enter the invoice number/numbers on which the shoe/boot was issued.

Sales Order Number*

Please enter the 5-digit number on the bottom of the white label on the front of your shoebox.

Fill in the names and genders of the wearers reporting defective footwear and the relevant information of the defective shoe/boot.*

Rows	First & Last Name	Gender	Shoe Model	Colour	Size
Wearer No. 1
Wearer No. 2
Wearer No. 3
Wearer No. 4
Wearer No. 5

Fill in the department and job title of each wearer and indicate if the wearer is on a shift.*

Rows	Department	Job Title	Shift Worker	Wear Period
Wearer No. 1
Wearer No. 2
Wearer No. 3
Wearer No. 4
Wearer No. 5

What are the working conditions of the wearers? Check all that apply.*

Rows	Wearer No. 1	Wearer No. 2	Wearer No. 3	Wearer No. 4	Wearer No. 5
Cement
Chemicals
Cut Hazards
Driving
Dry Warehouse
Extended Water Contact
Lengthy Standing Period
Puncture Hazards
None of the Above

Put any further information about the wearer's work conditions below.

Is the defective footwear still being worn?*

YesNo

Upload a clear picture of the shoe defect here. (One picture per defective shoe.)

Put any further information about the shoe defect below.

Upload a clear, close-up picture of the label on the tongue of the shoe here. (One picture per defective shoe)

Choose the tongue of any foot of the pair for the picture. The text on the label should be legible.

Upload a picture of the front of the box that the shoe came in, clearly showing the box labels. (One picture per defective shoe)

The front of the box is where the name of the shoe is.

Are you one of the wearers?*

YesNo

Desired remedy*

Replacement of same model and size (free of charge)Full refund (applicable only if return is made within 20 days of the purchase)Exchange for a different model or size (any price difference will be paid by the customer)Store credit for the full value of the returned item