ALLTRAX Inc.

1111 Cheney Creek Road

Grants Pass, OR 97527
Voice: 541.476.3565
Fax: 541.476.3566

Return Authorization Form:

[Please fill out the information below as completely as possible ]

RA# _________________ Date: _____________

(RMA Number will be issued by return fax upon completion of this form)

Customer: ___________________________, Contact: ____________________________

Address: _________________________________________________________________
Customer:

City: ______________________, State: _________, Zip: ____________, Country: ______

Phone: ____________________________, Fax: ________________________________
Email: (Optional) ________________________________________________________
Purchased Unit From: ____________________________________________________

THROTTLE TYPE:
0-5K_ohm NON-DEFAULT Configuration Setting
Controller:

Model: 5K-0_ohm
E-Z-Go_ITS Brake Max
SN# 0-5 Volts Current: Current:
6-10.5 Volts Ramp up:___________
Mfg Yamaha 0-1K_ohm
Date: ClubCar 5K to 0_ohm Ramp Dwn: _________ Speed:

Stock Car: Non-Stock Car: (Fill out below)

Model:
Equipment:

Motor Mfg: ________________ Lift Kit:

Fused?
Yes No
Make: Yes No Motor Model:_______________
Year: Battery Voltage: Tire Size:__________________ High Speed Gears:
Inch mm Yes No
VIN#: vdc
Please describe for
Failure Mode

Each Unit

Write the RMA number on the shipping box and ship unit to: Alltrax Inc.
See web site www.alltraxinc.com for RMA procedures and 1111 Cheney Creek Rd,
throttle configuration details. Grants Pass, OR 97527

Saved: 12/12/2008 1:56:00 PM Doc120-003-E_RMA-Form 1 of 1