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"*" indicates required fields

Name*

First Last

Company Name (if applicable)

Address*

Street Address Address Line 2 City State ZIP Code

*If found to be within the warranty period, this is where the replacement product will ship

Phone

Fax #

Email*

Information regarding the installation location of the product(s).

Company Name (if applicable)

Key Contact Person*

Address*

Same as address above

Street Address Address Line 2 City State ZIP Code

Phone

Email*

Fax #

Type of Installation*

In original fixture

Retrofit

After-market installation / replacement

New construction / large renovation installation

OEM product assembly

Select Type

Catalog No. (indicated on product label)*

Quantity Not Working*

Date of First Failure*

mm/dd/yyy

Date Code or Age of Product*

See our warranty page for more information.

Nature of Problem*

Failed to turn on after a period of time

Began flickering/shimmering/strobing after a period of time

Excessive corrosion, discoloring, paint blemishes, or other physical damage

Other (add details below)

Additional Details

Comments