First Nation Group Med-Surg Return Form

We value our customers and their needs. Please complete the following Return Authorization Form, and a First Nation Group representative will follow-up with you directly.

Returns

VA Facility *Please include city and state.

Contact Name *

First

Last *

Last

Contact Phone Number

Extension

Contact Email Address *

Purchase Order Number (PO) *

Date of Invoice (MM/DD/YYYY) *

*Invoices older than 90-days will be reviewed for approval

Item Number and Quantity Returning *

*If everything, say "ALL"

Serial Number(s)

*If returning only a portion of the order

Reasons for Return *

Any additional applicable notes?

Name of Contact Completing Return Form

First

Last