Name *

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Home Number *

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How did you Purchase Your Adjustable Bed * OnlineLocal StoreCatalog Mail OrderCatalog Phone Order

Date of Purchase *

Store Where Purchased *

Store Address: City, State, Zip *

Store Purchased Phone Number: *

Model Number: * SS2733TXLSS2746FSS2750QSS2766KSS3033TXLSS3050QSS3133TXLSS3146FSS3150QSS3160CKSS3166KSS3233TXLSS3246FSS3250QSS3260CKSS3266KSS3333TXLSS3346FSS3350QSS3360CKSS3466KSS3346FSS3450QSS3460CKSS3466KGS5033TXLGS5046FGS5050QGS5060CKGS6033TXLGS6046FGS6050QGS6060CKGS6133TXLGS6146FGS6150GS6160CKGS7033TXLGS7046FGS7050QGS7060CKGS7133TXLGS7146FGS7150QGS7160CK

Adjustable Base Size * TwinTwinXLFullFullXLQueenSplit QueenSplit KingCal KingSingle Piece King

Color * MochaGraphiteSmokey Charcoal

Serial Number *

Serial Number for 2nd Base (King Size Only, 2 Required) *

Purchase Price Paid *

Store Invoice or Transaction Number *

Yes, I purchased an Extended Warranty

Extended Warranty Information: (Company, Address, Phone Number)

Extended Warranty Years of Coverage

Extended Warranty Cost

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