Name

First

Last

Phone No.

Email

Address
Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Name of and Place where Firearm Purchased*

Original Owner?*
YesNo

Model Number*

Serial Number*

Brand of Mag Used (ex. Promag, Xtech, P-mag, etc)*

Brand of Ammunition Used*

Total approximate rounds fired to date, prior to experiencing issues*

Experienced Failure to Fire?*
YesNo

Experienced Failure to Feed round into chamber?*
YesNo

Experienced Failure to extract empty casing out of barrel?*
YesNo

Experienced Failure to Eject empty casing out of rifle?*
YesNo

Provide Explanation of Problem

Upload Photo of Problem when Possible