Tech Support/RMA Request (*Required) Contact Information Request Type* Tech Support RMA First Name* Last Name* Company Name Street Address* City/State/Zip* AL AK AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY (5-Digit Zip Code) Daytime Phone* (  )  -  Fax (  )  -  Email Address* Contact Method - Select One - Email Phone Fax Product Information Product Type* - Select One - TFT-LCD Panels LCD Monitors PC Cooler Model No.* - Select One - MV140 MV141 MV151 MV152 MV170 MV171 MV173 MV173V MV174 MV175 MV176 MV177 MV177V MV178 MV179 MV190 MV191 MV192 MV190T MV192T MV220 MV240 BTF95 BTF90 BTF80 CF900 CF800 GX810 GX710 GX700 Serial No.* Date of Purchase* / / (MM/DD/YYYY) Store/Reseller Name* Purchase Location* City State AL AK AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Other Comments
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