* First Name:

* Last Name:

* Email Address:

* Confirm Email Address:

* Address Line 1:

* City:

Address Line 2:

* State:

* Zip/Postal Code:

* Phone Number:

* First and last name of check recipient: 

Disabling or destroying the eWAGON (model #3912) is mandatory to receive a full refund of the purchase price. It allows us to verify that the eWagon cannot be accidentally used or resold, and allows us to process your refund as quickly as possible.

Click here to view instructions for cutting the wires.

* Please upload an image of the cut wires and the handle (JPG only, max 3 MB):
Image must show the the cut wire and the handle.
Additional images may be required.

* Please upload an image of your proof of purchase. (JPG only, max 3 MB):
Order Number must be included and will be validated with retailer.

* I agree that by completing this form, uploading an image of the cut wires from the handle and requesting a refund for the eWagon (model #3912), I have disabled or destroyed the product and I will not use or sell the product in the future. I understand that I need to retain the wagon until the reimbursement check has been received.