6520 Powerline Road, Fort Lauderdale, FL 33309

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Lotus Sales Rep

Dealer/Retailer: *

Address: *

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Phone Number *

Email *

End User Name: *

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Job Address: *

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Material Information

Original Invoice/PO# *

Product involved in claim: *

Quantity (SFT) *

Date claim was reported: *

Installed? *

Installed over 6mil moisture barrier? *

Installation Date:

Installers Name:

Installer's Phone Number:

Describe the problem, details of complaint, and requested solution *