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Return Authorization Request Form
(www.clean-usa.com)

Please be sure to complete all fields to include your full name, address, order number and e-mail address. This will enable us to identify your order and to issue you with a RA#. To be eligible for an exchange or a refund, items must be returned within 30 days of purchase.

* Required Fields

Date of Purchase:* (mm/dd/yy)          Order ID-number:*
                                                                                       (V-number)

Contact information:

* First Name:

* Last Name:
Street Address:
Address (cont.):
City:
State/Province:
Zip/Postal Code:
Country:
*E-mail:
Work Phone:
Home Phone:

Returned Item Information:

QTY     DESCRIPTION (select )                                            ACTION REQUIRED (select)

BILLING
Credit Card
Cardholder Name
Card Number
Expiration Date
Customer Service - Returns
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