Earn free factory service when you refer a friend

Owners: Complete this form to submit your referral

Send your referral information to Givens Marine Survival CO., INC. by fax (just print this page from your browser and fax it to the number above) or press the submit button after filling out this form to file electronically. If the referral results in a purchase, you will receive a Free Factory Service Inspection by one of our experienced life raft technicians.

Please NOTE: This is for a Free Service Inspection, parts, repairs and shipping not included.

*Indicates a required field.

Referral's Name*

Referral's Daytime Phone* ext.

Referral's E-mail*

Referral's Street Address*

Referral's City

Referral's State* Zip Code*

Referral's Country*

Your Name*

Your Daytime Phone* ext.

Your E-mail*

Your Street Address*

Your City*

Your State* Zip Code

Your Country*

Have you previously purchased a Givens Life Raft? Yes No

Year

Model

Date last serviced

Comments or Questions?