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Model Name

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Date Code

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Date Code

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Model Name

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Date Code

Please Select 21-4 21-5 21-6 21-7 21-8 21-9 21-10 21-11

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Model Name

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Date Code

Please Select 21-4 21-5 21-6 21-7 21-8 21-9 21-10 21-11

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Add another unit

If you have more than 20 units, please fill out another form.

I acknowledge my responsibility to destroy the defective cable and have done so

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