complaint form

COMPLAINT FORM
Form no.:
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Date:
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Customer name:
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Customer phone:
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Stamp or company details
Customer address / Shipment address:
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No.
Product, lot number
Quantity
(pcs.)
Malfunction information
Malfunction type
Conditions in which fault occurs
Method of verification
1
2
3
4
5
Customer signature:
Complaint form receiver signature:
...............................................................................
...............................................................................
Please attach copy of invoice or another sales receipt.
Please do not erase error codes and delete maps.
We kindly request for giving us as much information as it is
possible, that is highly effective in helping to find and solve the fault.
tel. +48 85 734 13 10
NIP: 9662055105
REGON: 200411375
LPGTECH Sp. z o.o. ul. Dojnowska 67, 15-557 Białystok, Poland
fax. +48 85 733 68 78
Sąd Rejonowy w Białymstoku, XII Wydział Gospodarczy Krajowego Rejestru Sądowego;
Numer KRS: 0000374066; Kapitał zakładowy Spółki : 120 000 PLN; Bank Zachodni WBK S. A. 72 1500 1083 1210 8010 8922 0000