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RxAuto Retreat Authorization Form

RxAuto Retreat Authorization Form

Retreats are only available during the 90-day warranty period.

Please completely fill out the following form. Any fields left blank will delay the processing of your retreat!

Full Name
Name Order was Places Under:

E-Mail:

Invoice Number:

Date of Purchase:

Method of Payment:
Credit CardPaypal*

Refund Authorization Number:
(Given by Technical Support Representative)

Make of Vehicle:

Year of Vehicle:

Model of Vehicle:

Number of Cylinders:
468

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I am requesting a Thermagasket retreat in Lieu of refund. Acceptance of this retreat releases RxAuto Thermagasket LLC of any obligations under the expressed written warranty!

I agree to be billed as follows for Shipping and Handling:

Inside the United States $21.00
Canada or Mexico $39.00

Your Digital Signature acknowledges you agree to abide by the above terms

Authorizing Digital Singnature:
Type Name Here

What is 62 − 55 =

Once we have received this form you will be sent a password protected link within 24 hours to complete payment for Shipping & Handling. The password will be good for 24 hours.

RxAuto Retreat Authorization Form

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RxAuto Retreat Authorization Form

Please Read

Company

Infomation

Account

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