Bushnell

Please print all information below and rubberband this form to the unit being sent in.

Contact Information
Customer Name:
E-mail:
Home phone:
Cell phone:
Work phone:

Return Address
Address:
City:
State:
Zip:

Product Information
Brand Name:
Product Category:
Product Description:
SKU Number:
Number of years owned:
Description of problems:	Please tell us what problems you are experiencing.
Is this Bolle Rx or Serengeti Rx eyewear?	YesNo

3rd Party Returns (used by retailers sending in product for their customer to be fixed)

Customer Name:
Your Reference Number:
Bushnell 6 digit Account Number (if applicable):