External Capture Form

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New Capture

Application:

Transportation

Telecom

UPS

Customer Name:

Contact Person:

Phone Number:

Phone Extension:

Address 1:

Fax:

Address 2:

Email:

City:

Zip Code:

Country:

Date Warranty Received:

State:

Battery Distributor:

Site Information

Site Name:

Address 1:

Address 2:

City:

Zip Code:

Country:

State:

Installation Date:

Quantity Per String:

Climate Controlled:

Yes

No

Battery Type:

Quantity:

Replacement:

Yes

No

Warranty Credit:

Yes

No

Returning Product:

Yes

No

(Anonymous)

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