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Warranty Form
Dealer Claim Number :
Dealer Name :
Address1 :
Address2 :
City/State/Zip :
Phone :
Dealer Contact Person :
Customer Name :
Customer Address1 :
Address2 :
City/State/Zip :
Customer Phone:
RGA Number Requested?
Assigned by RPM
Machine Model :
RPM Part Number :
Date Installed : (MM/DD/YYYY)
Date of Failure : (MM/DD/YYYY)
Machine Serial Number :
RPM Serial Number :
Hours at Installation :
Hours at Failure :
Description of Failure :
Parts Cost(US$) :
Labor Cost(US$) :
Total Cost(US$) :
Comments :
Signed :
Date : (MM/DD/YYYY)
2003-2008. All Rights Reserved.
All data protected by RPM Industries,LLC. No unauthorized use or disclosure is permitted.