Name *

First Name

Last Name

Phone *

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

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Purchase Date *

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Have you used and maintained the product in accordance with the provided user manual and any additional instructions provided by the manufacturer? *

Yes

No

Has the product been subjected to any unauthorized modifications? If so, please provide details. *

Yes

No

I hearby declare that the information provided is true and accurate to the best of my knowledge. *

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DD

YYYY