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)

Postal code (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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