Return Request

Date

Name

Address

Phone

Name

Address

Phone

Please complete this form in its entirety, click submit and send us a copy along with the product.

Product(s)

Quantity

Problem:(Please be as specific as possible.)

PO #

Purchase Date

Recurring Problem?

Install Date

Process Fluid

Conc. of Process Fluid

Process Fluid Temp ( Max )

Solids/Particulate

Process Pressure ( Max )

Process Fluid Velocity ( Max )

Upload Image:

(please provide pictures of the product in the working location)

Additional Notes