Please fill out one the form below and your request will be directed to the correct department. Empire Merchants will respond within two business days.
Submitted By *
Email: *
Customer Number *
Order Number *
Customer Phone Number
Problem * BreakageUnsaleableOrdered Wrong ItemShort on truckQuantity Discount CreditDelivered Wrong ItemMis-priced itemInvoice DisputeRequest Delivery InstructionsRequest Copy of InvoiceRequest Copy of StatementRequest Copy of Credit Memo
Invoice # *
Invoice Date *
# of Broken Bottles *
Quantity shorted *
Action * Exchange
Quantity (cases or bottles) *
Item # Billed For *
Item # received *
Quantity *
Item # Shorted *
Quantity Shorted *
Invoice # 1*
Invoice Date 1 *
Invoice # 2 *
Invoice Date 2 *
Item # *
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