NOTE: If you need more than four different parts
please call our Customer Service number for assistance

  Your Name ....................................

  Street Address .........................
                 .........................

  City ....   State .....   Zip Code ....

  Tel. No. (in case there is an issue with delivery) .....

  Email Address ....................




        			Please indicate which Product you purchased:

                  Product Model No.......     Product Color.......

				What part(s) do you need for this product?

      FIRST PART

   Part # or Letter (see manual)..
   Quantity needed................
   Reason part is needed..........

SECOND PART

   Part # or Letter (see manual)..
   Quantity needed................
   Reason part is needed..........

THIRD PART

   Part # or Letter (see manual)..
   Quantity needed................
   Reason part is needed..........

FOURTH PART

   Part # or Letter (see manual)..
   Quantity needed................
   Reason part is needed..........



                                                

d-Scan, Inc.
Email d-Scan
or call Customer Support at 1-800-932-2006 -- fax to 1-434-575-0946
Monday - Friday: 8:00 am - 5:00 pm Eastern Time

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