REQUEST TO RETURN PART

DATE: ____________________________________

FROM: __________________________________________ (name)

__________________________________________ (facility name)

__________________________________________ (Phone)

TO: __________________________________________ (name)

__________________________________________ (facility name)

On _____ / ______ / ______ (date) we purchased the following part(s) from you with purchase order _____________. Your invoice # is ______________________

YEAR MODEL PART/IC#/OEM# COST

_________ _____________________________ ________________________________________ $__________

_________ _____________________________ ________________________________________ $__________

_________ _____________________________ ________________________________________ $__________

_________ _____________________________ ________________________________________ $__________

_________ _____________________________ ________________________________________ $__________

_________ _____________________________ ________________________________________ $__________

Tax $__________

Shipping/Handling $__________

Total $__________

We would like to return the part(s) shown above to you for the following reason(s):

¨ Part damaged on arrival ¨ Not the correct part

¨ Our customer refused part ¨ Our customer never returned

¨ Order canceled before part arrived ¨ Mechanical Failure

Once the part arrives at your facility, please fax a credit invoice in the amount of $__________ to ______-______-_____________

SELLER’S AUTHORIZATION

Your request to return the parts shown above is ¨ approved ¨ denied.

Once the part arrives at our facility we will fax a credit invoice in the amount of $__________

________________________________ (print name)

___________________________________(sign)

_____________ (date)