NextTronics Rebate Request Form

Complete the form below.  This page should be completed, printed and included with a copy of your invoice and the defective item you are replacing

CONTACT INFORMATION

*  denotes required field

Company:

Name *:

Street Address*:

City, State, Zip Code, Country *:

   AK AL AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA WV WI WY

Phone number *:

Additional phone number:

Email Address:

Date you received the item *:

Invoice Number*:

from invoice

Item Price*:

from invoice

Item Description*:

from invoice

Rebate Amount *:

from invoice

Tracking number from from NT*:

on the shipping label on package you received

Delivery company from NT*:

---- DHL FEDEX UPS USPS found on the shiping label on the package you received

Delivery confirmation to NT*:

Delivery company used to ship to NT*:

---- DHL FEDEX UPS USPS

*

I understand that NextTronics will issue a rebate only if this form, a copy of the invoice and the defective item being replaced (core) is returned within 30 days from the day I received my item. (We will use the tracking number to verify the delivery date)

*

I understand that I am responsible for any shipping cost to return the requested items to NextTronics and it is my responsibility to record the return tracking number.