REQUEST FOR REPAIRS, AND/OR ACCESSORIES
INSTRUCTIONS WHEN REPAIRS ARE NEEDED 1. Please complete items 1 through 8 and check appropriate box in Section I - Repairs that best explains your reason for returning the device for repairs. 2. Wrap device (including transmitter, receiver, cords, tubing, etc.) in a protective foam blanket or some other protective product and place in a postal pouch with this form and mail too: Department of Veterans Affairs, Denver Distribution Center, P.O. Box 25166, Denver, CO 80225-0166. DO NOT SEND earmold, presentatin case, eyeglass fronts, etc. WHEN ACCESSORIES ARE NEEDED FOR THIS DEVICE 1. Please complete items 1 through 8 and Section II - Accessories. Indicate item(s) needed, cords, rubing, wax guards, earhooks, etc. Please indicate length when ordering cords or straight tubing. 2. Place defective items (cords or tubing if necessary) in a postal pouch along with this form and mail too: Department of Veterans Affairs, Denver Distribution Center, P.O. Box 25166, Denver, CO 80225-0166.
1. LAST NAME, FIRST NAME, MIDDLE INITIAL 2. DATE OF BIRTH (MM/DD/YYYY) 3. LAST FOUR DIGITS OF YOUR SOCIAL SECURITY NO. 4. DATE MAILED (MM/DD/YYYY)
5. HOME MAILING ADDRESS 6. MAKE
DEVICE INFORMATION 7. MODEL
8. SERIAL NUMBER(S)
SECTION I - REPAIRS
1. DESCRIPTION OF DEFECTS (Check appropriate box(es)) DEAD NOISY 1. ITEM(S) NEEDED 2. REMARKS FADES WEAK INTERMITTENT DISTORTED MOISTURE DAMAGE EXCESSIVE BATTERY DRAIN TELE COIL DEAD/WEAK FEEDBACK
SECTION II - ACCESSORIES
VA FORM JUN 1998 (RS)
1107
(Electronic version)
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