Test3

Warranty Form

Personal Information

I am an:

Country Country is mandatory

State or Province State or Province is mandatory

Street Address Street Address is mandatory No P.O. Boxes

City City is mandatory

Telephone Telephone is mandatory No spaces or dashes

Email Email is mandatory

TIRE CLAIM FORM 1

Purchase Information

Tire originally fitted to bicycle when purchased new?

A choice is mandatory

Purchase Date Purchase date is mandatory

Retailer Name

Retailer Phone Number or Website

Tire Information

Select Model Model is mandatory

Defect Information

Reason For Claim Reason for claim is mandatory

Description of Defect Description is mandatory

Sealant Used?

A choice is mandatory

Defect Images | Image is required with a file extension of jpg, png or gif and 5 MB Max.

Image of Label or Hot Patch | Image is required with a file extension of jpg, png or gif and 5 MB Max.

Image of Production Code | Image is required with a file extension of jpg, png or gif and 5 MB Max.

Proof of Purchase | Image is required with a file extension of jpg, png or gif and 5 MB Max.