RETURN GOODS MEMO

S.A.M. BRAKE, INC.

314 RAILROAD AVENUE

HACKENSACK, NJ 07601

TEL. (201) 342-0636 FAX (201) 342-9351

RECIEVED

FROM

DATE:

WRITTEN BY:

ORDER #:

UMP INV.#:

SPECIAL INSTRUCTIONS

	QTY. RET.	QTY. REC.	QTY. CODE	ITEM

RETURN CODES:

N = New Material

D = Defective Material

C = Core

For Office Use Only:

Sale Verification:

Credit Given By:

Invoice #:

Date: