BemesOnline Repair Request Form

BemesOnline Repair Request Form

PLEASE FILL THIS OUT AND SHIP IT WITH YOUR MACHINE TO: BEMES, INC, 111 LEUNING STREET, UNIT A, SOUTH HACKENSACK, NJ 07606. PHONE: 866-490-1609 INTERNATIONAL: 201-297-6686
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Model:*
Serial Number:*
Description of Issue:*
Please print this out and send it with your machine.

Please only send the unit and the power supply. Do not include any hoses, masks, water chambers or other disposables. They will be discarded to avoid cross contamination.
Please verify that you are human*
Should be Empty:

Please print this out and send it with your machine.