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Contact Name(*)
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Company Name(*)
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Address (Street)(*)
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City / Town(*)
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State / Province(*)
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Zip / Postal Code
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E-mail(*)
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Phone(*)
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Purchase Date:
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Rex Sale Order (Packing List #)
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Customer Purchase Order #(*)
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Reason for return(*)
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Catalog No.(*)
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Quantity(*)
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Additional Notes
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Upload Picture File (if you have)
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