30
PARTS REQUEST FORM
Paradigm Health & Wellness, Inc.
EMAIL THIS FORM WITH YOUR RECIEPT OF PURCHASE TO
Service@paradigmhw.com
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 to #: 626-810-2166
PART #
DESCRIPTION
QTY
Summary of Contents for 1317.5-101016
Page 2: ......
Page 5: ...3...
Page 6: ...4 LABEL PLACEMENTS...
Page 8: ...6 OVERVIEW DRAWING 1 1 6 1 1 6 1 3...
Page 12: ...10 HARDWARE TOOLS PACK...