Who is Submitting this form? (required)
End UserTechnician - For End UserStore - for End UserStore - Floor Model

Purchase Receipt (must include date) (required) (5 MB Limit)

Serial Number (required)

Chair Model Number (required)

Chair Color (required)

Detailed Description / Error Code (required)

Name (end user) (required)

Email (end user) (required)

Phone Number (end user) (best contact) (required)

Address (required)

Date Purchased (required)

Store Purchased at (required)

Attach Pictures

Picture 1 (optional) (5 MB Limit)

Picture 2 (optional) (5 MB Limit)

Picture 3 (optional) (5 MB Limit)

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