SelectPOS Advanced Exchange Request

Please complete information below. Your unique Advanced Exchange number is displayed at the top of this form. Please use this number when communicating with Select POS about your repair. Upon completion of this form, an automated email will be sent to you confirming your Advanced Exchange information. Thank you!

Date:

Advanced Exchange #
(Please reference this number when sending in your Core Exchanges.)

Company Name:

Bill to Address:

Attention:

Street Address: City:

State: Zip:

Ship to Address: same as Bill to Address

Company Name:

Attention:

Street Address: City:

State: Zip:

Contact Name*: (* required fields)

Phone Number*: Email Address*:

Request Items for Exchange:

Manufacturer

Device

Part

Quantity

Your Reference or PO #: (Required before order will ship)


•	Core returns, with CORE TAGS, must be received within 14 days to prevent additional billing
•	Incomplete and Non-Repairable cores will result in additional charges
•	Contact your sales rep to arrange for an Outright Purchase of these items

Comments (Please include any special requirements, such as software revision level):

Return shipments will be shipped UPS Ground (Uninsured) unless
otherwise indicated in the Comments area above.

PLEASE NOTE: Select POS is NOT responsible for ensuring Patient Readiness upon receipt.
Six month warranty will cover all parts and labor associated with the repair of items,
cosmetic and physical damage will be billed back to the customer.



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©Copyright 2008, All Rights Reserved. Select P.O.S. & Peripherals, LLC. For more information contact us at 1.866.559.3500 or email information@selectpos.com