EmailMe Form - Warranty Application form

Shop Name *

Contact name *

Account Number

** Staff use only

Address *

Street Address City State / Province / Region Postal / Zip Code

** Need not fill this out if you are an account customer

Email *

Phone *

Date of purchase *

DD / MM / YY

If brand new and unsold, put todays date

Helmet Brand *

Adura

Pit

Model *

Failed part *

Retention System

Cosmetic damage

Exterior shell

Straps

Failure / Fault description *

Proof of purchase *

For helmets that are NOT brand new.

Helmet Image *

Failure Image *

Extra File Upload if needed

Submitted By *

Store

Sales Rep

James Huang

Jason Eve

Matt James

Heinrich Stroebel

Nathan Bradbery

Craig Brown

If you want your sales rep CC'd into this warranty process, check the name of your sales rep. This is not required.