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      Return for Repair - please submit one form for each part number

Company :  
Account # (if known)  :  
Requester Name :  
Requester Title  :  
Phone #  :  
E-mail Address  :  
Return Information 

QTY

 :   Manufacturer :
Part # :   Lot #  : Ser # :
Original Purchase PO#  :   Purchase Date  :
Repair Information
Have these parts been modified at all?
What is the application?
How did the unit fail,and how was the part being used during failure?
How many other units have failed in this application?