27
PARTS REQUEST FORM
Paradigm
Health & Wellness
, Inc.
EMAIL THIS FORM WITH YOUR RECEIPT OF PURCHASE TO
*
NAME:
_____________________________________________________________________________________
ADDRESS:
__________________________________________________________________________________
CITY:
________________________
STATE:
_____________
ZIP:
_______________________________________
TELEPHONE: (Day)
__________________________________________________________________________
(Night)
_________________________________________________________________________
SERIAL#:
___________________________________________________________________________________
MODEL#:
___________________________________________________________________________________
PURCHASE DATE:
___________________________________________________________________________
PLACE OF PURCHASE:
_______________________________________________________________________
“YOUR ORDER WILL BE PROCESSED WITHIN 3 BUSINESS DAYS”
* This form can also be faxed in Fax #: 626-810-2166
PART #
DESCRIPTION
QTY
