RMA Request

Directions: Please fill out the following information completely and click [Submit] when done. After your request is processed, you will be contacted with an RMA Number, along with further instructions if necessary. A service support professional will respond to your request within 8 business hours upon receipt of your request. During peak hours, response times may be longer.

      *=required

Bill to:
*Company:
*Address 1:
Address 2:
*City:		*State:	AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY	*Zip Code:
*Contact:		*Telephone:
E-Mail:		Fax:
Ship to:	Same as Bill to:
*Company:
*Address 1:
Address 2:
*City:		*State:	AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY	*Zip Code:
*Contact:		*Telephone:
E-Mail:		Fax:

Method of Payment (for units outside of warranty and not under contract)
Credit Card: Visa MasterCard American Express Credit Card Number: Name on Credit Card: Expiration Date: Month: 01 02 03 04 05 06 07 08 09 10 11 12 Year: Check: Prepaid Check COD: Collect on       Delivery **Purchase Order: PO w/Valid       Account No. N/A Under Warranty       or Contract
**User must have established terms with FLS INC. to submit a purchase order for repair.
Purchase Order Number:
**Account Number (Only for PO's):

Item 1 *Manufacturer: *Model#: *Part#: *Serial#: *Problem: *Valid Warranty: Yes No If product is under contract, Contract Number:

Item 2 Manufacturer: Model#: Part#: Serial#: Problem: Valid Warranty: Yes No provide the contract number below. Contract Number:

Item 3 Manufacturer: Model#: Part#: Serial#: Problem: Valid Warranty: Yes No If product is under contract, Contract Number:

Item 4 Manufacturer: Model#: Part#: Serial#: Problem: Valid Warranty: Yes No provide the contract number below. Contract Number:

Item 5 Manufacturer: Model#: Part#: Serial#: Problem: Valid Warranty: Yes No If product is under contract, Contract Number:

Item 6 Manufacturer: Model#: Part#: Serial#: Problem: Valid Warranty: Yes No provide the contract number below. Contract Number:

Item 7 Manufacturer: Model#: Part#: Serial#: Problem: Valid Warranty: Yes No If product is under contract, Contract Number:

Item 8 Manufacturer: Model#: Part#: Serial#: Problem: Valid Warranty: Yes No provide the contract number below. Contract Number: