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Complete and submit this information within 45 days of purchase to validate your warranty and receive 1 FREE bulb for product purchased.
Product Information
Model Number:
Serial Number:
Purchase Date:
Customer Information
Name:
Company:
Title:
Address:
Phone:
Fax:
E-mail:
Is this facility a (please check one):
Physician's Office
Specialty:
Clinic/Surgery Center/Hospital
Department:
Dealer
City & State:
Did you order this product(s) for:
Replacement
New Construction
Remodeling
Which factors influenced your decision to buy this product:
Quality
Performance
Dealer Recommended
Other
Did you compare this product to other competitive units?:
No
Yes
Which ones?
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