V A C U U M C L E A N E R W A R R A N T Y C L A I M S - P A R T S O R D E R F O R M
D E A L E R I N F O
DEALER NAME:
ACCOUNT #:
EMAIL ADDRESS:
C U S T O M E R I N F O
CUSTOMER NAME:
ADDRESS:
CITY | PROV | POSTAL:
---
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
PHONE #:
P R O D U C T I N F O
PRODUCT TYPE:
-choose a product type-
Countertop Coffee Machines
Canister Vacuum
Upright Vacuum
Accessory
MODEL #:
SERIAL #:
( 7-9 CHARACTERS )
LABOUR CLAIM TIER:
-choose a tier-
Tier1
Tier2
DATE OF PURCHASE:
( DD / MM / YYYY )
PROBLEM DESCRIPTION:
P A R T S R E Q U I R E D
PART #
QTY
1.
2.
3.
4.
5.
6.
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