Ballast Warranty Claim Form


Requestor: Job Site:
If same as requestor information, check here:
Company: Company:
Sylvania Account #:
Contact: Contact:
Email: Email:
Address: Address:
City: City:
State State
Zip: Zip:
Phone: Phone:
Fax: Fax:
Ballast to be shipped to other address:
Company: Same as requester
Contact: Same as Jobsite
Address: Other
Installation Information:
Have Lamps Been Changed?
Install Date:   mm/dd/yyyy
Ceiling Height:
Brief Description of Installation:
Brief Description of Issue:
Ballast Information:
  Ballast 1 Ballast 2 Ballast 3
Ballast Model #
Qty Installed
Qty Defective
Date Code (1)
QUICK 60+ # (if known)
Lamp Brand Installed
Lamp Model Number
Fixture Brand and Model

(1) Ballast date codes are located on the end of the ballast where the wires are or on the label of the ballast in the format "Year/Week" e.g. 0816 = the 16th week of 2008.