Warranty Form – Barksdale Sales Group

Name *

First

Last

Email *

Company Name

Product #1

Product #2

Product #3

Product #4

Quantity

Quantity

Quantity

Quantity

Reason

Reason

Reason

Reason

Please attach photos of damaged items. *

Drag & Drop Files, Choose Files to Upload

Associated Labor & Damage Claims *

Distribution Center City & State: *

RectorSeal PO Number: *

Reference Number (optional):

Requesting *

Shipping Address

Address Line 1

Address Line 2

City

State

Zip Code