Defect Complaint Form

Communication Address: SOLUQA Technology s. r. o., 1. mája 2598/43, Pezinok 902 01, Slovak Republic

Customer

Full Name:

Address:

Phone Number / Email Address:

Claimed Product/Service

Purchase Document or Warranty Certificate Number:

Product/Service Name:

Purchase Date:

Accessories Included:

Description of the Defect:

I propose that my complaint be handled in the following manner /please check the requested option/:

□ Product Exchange
□ Product Repair

If the complaint is resolved by a refund and you wish to receive the money via bank transfer, please provide your account number:

In .................................... on: …………………

............................................

Customer's Signature