Product Return Form
QAL 135 REV 2-8/19/05
Ref #
16639
** Fields are Mandatory
Dealer
Distributor
Distributor ID
**
Core
New
Remanufacture & Return
Repair & Return
Check & Advise
!!! Please Check anyone of the above checkboxes
Name
**
Account
**
Date
Address
**
City
**
St
Zip
**
Contact
**
Tel
**
E-Mail
Add More Items
Delete
Part#
Core Class
Description
Qty
Rtn
Qty
Rec
Notes #
Rec By
Date
Ent By
Date
Ship Product to: DSS ProDiesel, Return Goods Department, 318 Fesslers Lane, Nashville, TN 37210