Other Product 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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None-Laptop Battery Information

Company the lamp was purchased from*

Date the lamp was purchased*

Order / Case #

Model of the device the battery is being used with*

Model# of BTI Battery*

Serial# of BTI Battery*

Detail of problem & comments*

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