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Ship to:
Facility: ______________________________
Address: ______________________________
______________________________
City: ___________________ State_____ Zip________
Telephone: (_____) _____ / _________ Fax: (_____) _____ / _________
Reminder: if no shipping choice is made, the least expensive way will be used.
Bill to:
acility: ______________________________
F
Address: ______________________________
______________________________
City: ____________________ State_____ Zip_________
Order placed by:
Name: ________________________________
Phone: (_____) _____ / _______ Ext.: ______
Email: _____________________________________
Model number: _________________________ Serial number: _________________
Part number
*If your chair is over eight (8) years old, no part orders will be processed without documented
inspection by a Champion approved technician and an extended life certificate.
SERVICE PARTS FORM
Please duplicate form for use
Purchase order #: ______________
Page no. / part no.
Champion Manufacturing Inc
2601 Industrial Parkway
Elkhart, IN 46516
Phone: 800-998-5018 fax: 574-293-5760
Shipping instructions:
Ground: ______
3
rd
2
nd
Next day: _____
No order will be processed
without a P.O. & SN number*.
Quantity
(25)
OM00REC Recliner Manual REV 8 080119
day: _______
day: _______
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