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Contact Name
: _________________________________________________
Company Name : _________________________________________________
Street Address
: _________________________________________________
City
: ___________________ Province/State: ________________
Country
: ___________________ Postal/Zip Code: _______________
Phone Number
: ___________________ Extension : ___________________
Fax Number
: __________________
Serial Number
Fax this form to Kontron's Technical Support department in Canada at (450) 437-8053
AUTHORIZATION REQUEST
Failure or Problem Description
RETURN TO
MANUFACTURER
P.O. #
(if not under
warranty)
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