Please complete the following fields to ensure the validity of your RETRAX cover warranty.

* = Required field

*First Name: *Last Name:

*Address: Apt #:

*City: *State/Province: *Zip Code:

*Telephone #: *E-mail Address:

*Serial #: (found underneath rolling cover on drivers side)

*Year Of Truck:

*Cover you purchased:

How did you first hear about RETRAX?

Please select your age group:

What reason(s) influenced the purchase of your RETRAX cover (select all that apply):