Return Kit Registration

Code Date

*Business Name

Customer # (distributors only)

Store # (retailers only)

*Contact First Name

*Contact Last Name

*Street Address

Street Address con't

*City / Town

State / Province

*Postal Code


*Telephone Number


I have notified my sub-accounts of this recall (distributors only)

     If no, please indicate why sub-accounts have not been notified.

By providing the information in this form and selecting register I acknowledge and agree that my information is stored, processed and accessed in the United States and subject to the laws of that country.  I further grant permission for the use of such data for the purpose of carrying out activities related to a product recall