Projector Lamp Submission Form:

Customer Information

First Name*

Last Name*

Company Name

Address 1*

Address 2

City*

State/Province/Region*

Zipcode*

Country

Phone*

Fax

Email*

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Projector Lamp Information

Company the lamp was purchased from*

Date the lamp was purchased*

Order / Case #

Model of the projector the lamp is being used with*

Model# of BTI Lamp*

Serial# of BTI Lamp*

Detail of problem & comments*

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Additional Information

Does the lamp fit the device?

Yes

No

Did the lamp work when it was first installed?

Yes

No

How long did the lamp work?

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