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Send to:
Jomita SRO |Karnikova 12 | Brno | 621 00 | Czech Republic

 

RETURN MATERIALS AUTHORIZATION FORM |

Billing Address Shipping Address
Name Name
Address Address
City                                       State       Zip City                                           State     Zip
Phone Phone
E-Mail

 

 

 

 

Please attach a copy of your sales receipt to the back of this form.  Is this equipment under Warranty?

YES_____ NO_____

Has this equipment ever been returned for the same problem? 

YES_____  NO______ 

Payment Method: 

Visa _____ MC _____ Discover _____ American Express _____ PayPal _____ 

Credit Card or Account Number: _____________________________  EXP Date _____/_____  CSC: _______

Packaging List: 

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Please explain in detail what is wrong with your product: 

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Signature:_________________________     Date:_________________________