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OM000PI PI Manual REV 5 080119
SERVICE PARTS FORM
Please duplicate form for use
Ship to:
Shipping instructions:
Facility: ______________________________
Ground: ______
Address: ______________________________
3
rd
day: _______
______________________________
2
nd
day: _______
City: ___________________ State_____ Zip________
Next day: _____
Telephone: (_____) _____ / _________ Fax: (_____) _____ / _________
Reminder: if no shipping choice is made, the least expensive way will be used.
Bill to:
F
acility: ______________________________
Address: ______________________________
______________________________
City: ____________________ State_____ Zip_________
Order placed by:
Purchase order #: ______________
Name:
________________________________
No order will be processed
Phone: (_____) _____ / _______ Ext.
: ______ without a P.O. & SN number*
.
Email: _____________________________________
Model number: _________________________ Serial number: _________________
Part number
Page no. / part no.
Quantity
Champion Manufacturing Inc
2601 Industrial Parkway
Elkhart, IN 46516
Phone: 800-998-5018 fax: 574-293-5760
*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.