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Quantum Rehab REF: COM/0102-2
Rev: 0 Date: 6/6/13
Approved by: Julie Piriano

Quantum Rehab Provider Standards Violation Notification

Quantum Rehab has developed provider standards for the benefit of our providers and the good reputation of Quantum Rehab products.

Violation of any of the standards will be investigated and may result in the termination of the provider's right to purchase Quantum Rehab products. Please note if you notify us of a violation, you will not receive a response regarding the outcome of our investigation and, if applicable, any action taken against the violator.

Please complete a separate form for each alleged violation.

Individual or Company Name:

Address:

,

Phone Number:

Nature, facts and/or evidence of the violation:

Date(s) of violation:

Format: dd/mm/yyyy Multiple dates seperate by commas(,).

Name of Product:

Model Number:

Additional Information and/or other Pride Internet/E-Commerce Policy Violation(s) Noted:

Pride Mobility Products Corp. © 1995-2017 Pride Mobility Products Corp. All rights reserved. (U.S.) 1-800-800-8586 - (Canada) 888-570-1113
Pride Mobility Products Corporation - Disclosure Statement Pursuant to Cal. Civ. Code 1714.43(a)