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