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Product Return Authorization Request Form

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Please use this form to return products for replacement or credit. For fastest response complete as much of the requested information as possible. Once this form is submitted and approved by Burle, you will receive an e-mail with your Product Return Authorization number. Use this number on the return carton as instructed in the e-mail. Failure to provide this number may cause delay in processing your return. 

Provide the required information as indicated.
       * - Denotes a required field for form processing.

Customer Name:*
Requested By:
Street Address:*
City*
State:*
Zip Code:*
Country:*
                 

Country 
Code:

 Area 
Code:*
         
Telephone No.:*
           
Fax No.:
E-mail Address:*
                     
Customer Reference
No.: (If applicable)
 Original Purchase
Order No.:
                        

BURLE Part No.:*

Quantity.:*

DateCode/
Serial No.:*

Purchase
Price:







No. of hours used: (If applicable)   

 

Complaint: (BE SPECIFIC) *
                   
 Product User Name: (If applicable)
 Contact Person:
Contact Street Address:
 Contact City:
Contact State:
 		Contact Zip Code:
Contact Country:

Country 
Code:

 Area 
Code:
          
Contact Telephone No.:
           
Contact Fax No.:
Contact E-mail Address:


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E-mail address: info@photonisusa.com