6520 N. Powerline Road, Fort Lauderdale, FL 33309

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Lotus Sales Rep

Dealer/Retailer: *

Address: *

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End User Name: *

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Job Address: *

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Material Information

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Product involved in claim: *

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Date claim was reported: *

Installed? *

Installed over 6mil moisture barrier? *

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Installers Name:

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