6520 Powerline Road, Fort Lauderdale, FL 33309

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Lotus Sales Rep

Dealer/Retailer:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Email

End User Name:

First

Last

Job Address:

Address Line 1

Address Line 2

City

State

Zip Code

Phone

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