Industry

MCB RECALL CUSTOMER RESPONSE FORM

This Customer Response Form is intended for Siemens Channel Partners and Direct Accounts, who purchased product directly from Siemens,to acknowledge receipt of the Product Recall Notice for the Siemens and Murray one inch, plug-in breakers, single and double pole, 15 through 50 amps.

If you did not purchase product directly from Siemens, then you do not need to complete this form.

Please complete this form and return it to the SiemensCustomerResponseCentervia email or fax to 678-297-8316. This form may also be downloaded from our website:

If you have purchased any of the identified catalog numbers with associated date codes directly from Siemens, and you still have these productsin your possession, please complete and return the RGA Request Form, which may also be found on the website.

If you have any questions, please contact 1-800-756-6996 and reference Siemens and Murray circuit breakers, 15 through 50 amps. Thank you for your cooperation in this matter.

Please indicate one of the following: (Please check the appropriate box)

A) We have already quarantined our inventory and processed our return.

B) We will submit the RGA Request Form for the inventory we have on hand.

C) We have no inventory on hand.

For those products no longer in your possession, indicate your preferred action below:

A)We will locate our customers and give them the Product Recall Notice for the Siemens and Murray one inch, plug-in breakers, single and double pole, 15 through 50 amps.

B)We will supply Siemens a list of our customers that may have the potentially affected products and allow Siemens to contact them directly.
Our customer list is attached (attach additional pages if necessary):

Customer Name / Customer Address / Order Number / Contact Name / Contact Phone Number

C) We do not have a list of our customers who have these products in their facilities, and we are unable to locate these products. No further action required by Siemens.

Your Company Name: Siemens Billing Account #:

MailingAddress: State: Zip:

Company Officer:

Title:

Contact Phone #:Email:

Signature: Date:

Siemens Industry, Inc.5400 Triangle Parkway10.10.07

Building Technologies Low Voltage DistributionNorcross, GA USA