What is your complete name?


* Last Name:     

* First Name:     

Middle Name:   


Where are you living at the present?


* Address:       


                           


* City / Town:   


* Province:       


* Zip Code:         


What's your landline number?:        


What's your mobile number?:         


* What's your email address?:         


PAIR 1

* What's your Havaianas style or model?  


* What's your Havaianas color?                  


* What's your Havaianas size?                    


If qualified, would you like to request for one size larger

(subject to availability)? We recognize the above indicated

size may increase by the time you receive your replacement pair.       yes no


* Where did you purchase it?                      


* When did you purchase it?                          


* Do you have proof of purchase or receipt?                                                yes no


Style of replacement pair is subject to stock availability. If unavailable, we will

replace with the closest style possible. Thank you.


PAIR 2

What's your Havaianas style or model?     


What's your Havaianas color?                     


What's your Havaianas size?                       


If qualified, would you like to request for one size larger

(subject to availability)? We recognize the above indicated

size may increase by the time you receive your replacement pair.       yes no


Where did you purchase it?                         


When did you purchase it?                          


* Do you have proof of purchase or receipt?                                                yes no


Style of replacement pair is subject to stock availability. If unavailable, we will

replace with the closest style possible. Thank you.


PAIR 3

What's your Havaianas style or model?    


What's your Havaianas color?                    


What's your Havaianas size?                      


If qualified, would you like to request for one size larger

(subject to availability)? We recognize the above indicated

size may increase by the time you receive your replacement pair.       yes no


Where did you purchase it?                        


When did you purchase it?                          


* Do you have proof of purchase or receipt?                                                yes no



Style of replacement pair is subject to stock availability. If unavailable, we will

replace with the closest style possible. Thank you.



* I have read and understood the mechanics of the program

       and hereby declare that all statements are true and correct.







       Note: If you wish to exchange more than three pairs, please fill-out another form.