Your Email Address: (Very Important)

Name of Customer:    Contact:
Phone #:   Fax #:
Address:   City:
Province: Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Other   Postal Code:

Product Line: ------------ Banner Bayside Compumotor Control Chief CTC Daedal Efector Encoder Fortress GaiTronics Gleason Hubbell Larco Red Lion Other

Part Number: Quantity:

Product Line: ------------ Banner Bayside Compumotor Control Chief CTC Daedal Efector Encoder Fortress GaiTronics Gleason Hubbell Larco Red Lion Other

Part Number: Quantity:

Product Line: ------------ Banner Bayside Compumotor Control Chief CTC Daedal Efector Encoder Fortress GaiTronics Gleason Hubbell Larco Red Lion Other

Part Number: Quantity:

Salesperson: Dave Siebert Harold Koenig Colin Gaffney Laura Koenig Clayton Corley Jamie Fletcher Kirk Klath Brent Bourque Bryce McDonald Darrell Deck Other

Reason for return:
(Please indicate in DETAIL the reported problem with the units.)

Please check one of the following:

Warranty Credit Repair Other