Page Title Public Notice Legal information You must have JavaScript enabled to use this form. First Name Last Name Name of Company Name of representative Address Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code E-mail address Telephone Name of store where heater was purchased City of store where heater was purchased Product Brand - Select -ChromaloxCenturionElectromodeWestcanDimplex For help on find your model number please see the diagram below this form Model Number - Select -GCH4800GCH4800BGCH4831CCONS4800ECH-48ECH4800BBCH4800DCH-4831DCH4831ADCH4831R Year of manufacture Please attach in support of the present form an invoice, a photo of the heater or a photo of the heater’s manufacture tag One file only.256 MB limit.Allowed types: gif, jpg, png, bmp, tif, pict, pdf. I Confirm - Select -Having disposed of my heaterHaving severed the power cord of my heater before disposing of itI still have the heater in my possessionI still have the heater in my possession and having cut its power cord Signature I affirm that all information provided in this form are true and accurate and I recognize that submitting a false claim could constitute a criminal offense. Date emarsys First Name: Last Name: Name of Company: Name of representative: Address: City: State: Zip Code (office): Email: Phone: Name of store where heater was purchased: City of store where heater was purchased: Product Brand: Model Number: Year of manufacture: *Subject: *Message: Yes, I would like to recieve special product/service offers
