[  ]  I would like to have the merchandise re-shipped immediately. If subsequent investigation yields a record that the product was delivered undamaged, I agree to pay any and all costs associated with the replacement of the merchandise and the investigation.

[  ]  I would like Laser Copier Cartridges .com to investigate my claim first and then replaced the lost/damaged merchandise once the investigation has been completed.

I have read, understood and agree to be bound by the Terms and Conditions of Sale (see http://lasercopiercartridges.com/terms.htm [link]) and the Return Policy (see http://lasercopiercartridges.com/returns.htm [link]) currently in effect.

Signed:_____________________________________________   Date:___________________

Name (please print):________________________________   Company:_________________

Your report must be signed and faxed to (503) 643-5379 or mailed to the address above and we will process it. A response will be emailed to you. It is the responsibility of the customer to ensure receipt of this form by Laser Copier Cartridges .com.