Petzl ZIGZAG standard exchange procedure

Location
Utah
On April 25, 2013, Petzl decided to recall all ZIGZAG mechanical Prusiks.

The new version of the ZIGZAG will be available in the United States and Canada in March 2014. A summary of all changes made to the product can be viewed here .

If you live in the U.S. or Canada and still own a ZIGZAG affected by the recall (serial number below 13108******), Petzl America has units available for immediate exchange. We request that you proceed to the ZIGZAG End User Return Authorization Form to take advantage of the standard exchange procedure for your ZIGZAG. All costs will be covered by Petzl. (For users outside of the U.S. or Canada, contact the After Sales Service Department in your country via our web contact form)

Note: This standard exchange procedure supersedes all previous compensation procedures.
 
Further clarity would be appreciated:

Unable to find my Province (or any other one for that matter)listed as an option on your form.
Also, upon completion of the form, it reverts back to a blank form in an endless loop. I didn't mind filling it out twice, but three or four times might start to suck.
 

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