Customer (End User Organization) Name:

Customer Contact Name:

Customer Shipping Address (for Replacements):

City State Zip

Customer Telephone #:

Customer Email:

Reseller/Location where defective units were purchased:

Date defective units were purchased:

Defective Product Information:

Quantity of defective units:

Seal Shield part numbers of defective units (engraved on the bottom of product):

Serial number(s) for the defective units (engraved on the bottom of keyboard or on tag on cord):

Please specify all defects, problems and the reason for the return in detail.