REPAIR REQUEST FORM FOR A PRODUCT DISTRIBUTED BY BACKLINE S.R.L.

COMPANY RESELLER PRIVATE CUSTOMER
Name / Business Name / Last Name and First Name(*):
Street
ZIP CODE
City
Prov.
Tax Code
P. VAT
Email
We authorize you to forward invoices for purchased products and services to the e-mail address above.
Phone
Fax

BELOW PLEASE ENTER YOUR END CUSTOMER INFORMATION (REQUIRED)

Customer Name
Customer Phone
Customer Email


Enter product data

Choose a brand
Model
Serial number of the product
Date of sale/purchase of product (dd/mm/yyyyy receipt applies)
Name of retailer



Description of defect


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