Part Request Form - Exerpeutic EXERWORK 1000 Owner's Manual

Paradigm Health &
EMAIL THIS FORM WITH YOUR RECEIPT OF PURCHASE TO
Service@paradigmhw.com
NAME:______________________________________________________________________
ADDRESS:__________________________________________________________________
CITY:________________________ STATE:_____________
ZIP:________________________
TELEPHONE: (Day)_______________________________________________________
(Night)______________________________________________________
SERIAL#:____________________________________________________________________
MODEL#:____________________________________________________________________
PURCHASE DATE:____________________________________________________________
PLACE OF PURCHASE:_______________________________________________________
PART #
"YOUR ORDER WILL BE PROCESSED WITHIN 3 BUSINESS DAYS"
*This form can also be faxed to #: 626-810-2166
PARTS REQUEST FORM
Wellness, Inc.
DESCRIPTION
28
QTY