Customer (End User Organization) Name:

Customer Contact Name:

Customer Shipping Address (for Replacements):

City State Zip

Customer Telephone #:

Customer Email:

VENDOR INFORMATION

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:

Operating System Product is Used on: Windows 8 Windows 7 Windows Vista Windows XP Apple 10.8 Mountain Lion Apple 10.7 Lion Apple 10.6 Snow Leopard Linux Other