Product was:
     [   ]  Partially Damaged 
     [   ]  Wholly Damaged
     [   ]  Lost in Transit

For Office Use Only                                  
     Date received:
     By whom:
Name:
Shipping Address:
     [   ]  Return for exchange
     [   ]  Return for refund
     [   ]  Return for in-store credit
     [   ]  Return for repair/replacement
     [   ]  Advanced replacement/return

Order Number:
Contact Name:
     Email:
     Telephone:
     Fax:
  Part Number Qty Date of Purchase Condition

Line 1

       [  ]  Damaged
[  ]  Undamaged
[  ]  Lost in Transit
Describe Condition:

 

Line 2

       [  ]  Damaged
[  ]  Undamaged
[  ]  Lost in Transit
Describe Condition:

 

Line 3

       [  ]  Damaged
[  ]  Undamaged
[  ]  Lost in Transit
Describe Condition:

 

Line 4

       [  ]  Damaged
[  ]  Undamaged
[  ]  Lost in Transit
Describe Condition:

 

[  ]  I would like to have the damaged/lost merchandise re-shipped immediately. If subsequent investigation yields a record that the product was delivered undamaged, I agree to pay all costs associated with replacement of the merchandise and investigation.

[  ]  I would like DiscountInkjetCartridges to investigate my claim first and then replace the lost/damaged merchandise once the investigation has been completed.

I have read, understood and agree to be bound by the Terms and Conditions of Sale (see http://discountinkjetcartridges.com/dc_shop//terms.htm [link]) and the Return Policy currently in effect (see http://www.discountinkjetcartridges.com/return_policy.htm [link]).

Your request must be signed and faxed to (503) 643-5379 or mailed to the address above and we will process it. A response will be emailed to you. It is the responsibility of the customer to ensure receipt of this form by DiscountInkjetCartridges.com.

Signed:_________________________________________________   Date:_______________________