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Swivel Model #
Dispenser Serial #
MFG Date

Station Information

Parent Company Name

*Station Contact Name

*Street Address 1

Street Address 2

*City

State/Province

Postal Code

*Country

*Email

*Phone Number

If you wish to have your replacement parts shipped to another location than the one listed above, please fill out the Ship To Information below.  If not, please scroll to the bottom of the form and click Submit to complete your Registration.

Ship To Information

*Contact Name

*Address 1

Address 2

*City

State/Province

Postal Code

*Country

*Phone Number

*By clicking "I Agree" below, I declare under penalty of perjury under applicable law that, to the best of my knowledge and belief, the information I have given on this form is true and correct. I understand that my failure to provide truthful, accurate, and complete information may delay processing and shipment of replacement swivels. I hereby certify that I will discard and dispose of the Affected Swivels as instructed, and that I will not reuse or sell the Affected Swivels.

By providing the information in this form and selecting Submit, 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

Submit