This document is a customer refund application form for Immunotec products. It contains fields for the entrepreneur's and customer's contact information, as well as details of the product being returned such as quantity, date sold, and lot/expiration date. The form notes the conditions and requirements for submitting a customer refund, including that Immunotec must receive the completed form within 30 days of the entrepreneur providing the refund, all information must be accurate and complete, and it must be accompanied by packaging with the lot number and sales slip. Immunotec reserves the right to refuse applications that do not meet these requirements.

1. IRL-4
CUSTOMER REFUND APPLICATION
292 Adrien-Patenaude Order desk: (888) 462-3397 (M-F 8:30am - 6:00pm ET)
Vaudreuil-Dorion Fax: (877) 424-5050 24 hrs/day, 7 days a week
Quebec, Canada Customer Service: (888) 917-7779 (M-F 8:30am - 5:30pm ET)
J7V 5V5 Internet address: www.immunotec.com
Please use a pen and print clearly in all the spaces provided.
ENTREPRENEUR INFORMATION Portfolio Number:
NAME:
Last First Middle
Address:
City: State / Province: Zip / Postal code:
( ) Fax: ( )
Independent Entrepreneur’s Signature
RETAIL CUSTOMER INFORMATION
NAME:
Last First Middle
Address:
City: State / Province: Zip / Postal code:
( ) Fax: ( )
Retail Customer’s Signature
Product Qty Date sold Lot # / Exp. Date
CUSTOMER REFUND WARRANTY CONDITIONS AND REQUIREMENTS
1. The Customer Refund Application form is used for Immunotec products sold by an Immunotec Independent Entrepreneur to a Retail Customer.
2. Immunotec Research Ltd. must receive the Customer Refund Application form within thirty (30) days of the Entrepreneur providing the cash refund to
the Retail Customer. Replacements will be shipped to the Entrepreneur’s address on file.
3. All information on this form must be accurate and complete. Incomplete forms will be returned to the Immunotec Independent Entrepreneur.
4. All Customer Refund Application forms must be accompanied by the portion of the package displaying the lot number(s) and the Independent
Entrepreneur’s copy of the Sales Slip.
Immunotec Research Ltd. reserves the right to refuse any Customer Refund Application requests or forms
for failure to meet any one of the requirements stated above.
Forward Customer Refund Application Form to:
Immunotec Research Ltd.
Customer Refund Warranty Department
292 Adrien-Patenaude, Vaudreuil-Dorion (Quebec) Canada J7V 5V5
Printed in Canada