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                SERVICE REQUEST FORM


If an RGA is requested, the product must be at the dealer/store location. If a pick up has been scheduled and Assura cannot retrieve the RGA because the product is not at the dealer/store location, trip charges may apply.


DEALER INFORMATION

Where was product purchased

Person Reporting the Defective Product
Purchase Order used to buy the products
If Unknown, Dealer/Store PO is adequate
Please select from the Drop Down Menu, if other, please type info in Comments

What is wrong with the product?

INSTALLER INFORMATION

CUSTOMER INFORMATION
Please insert a picture of the problem

Please attach at least one photo

Please insert a picture of the problem 
Please insert a picture of the problem 
Please insert a picture of the label
Please insert a picture of the problem
Please insert a picture of the problem
Please insert a picture of the problem