Claim report – Adast Systems

Customer

Your name

Customer address

Street

City

Zip code

Country

Claim No.

Customer Ref. Number

Other Ref. Number

Date Issued

Contact person

Phone

E-mail

Complaint

Place and address of installation

Place

Address

City

Country

Dispenser's Ser. No.

Date of installation

Totalizers status

TOT no. 1

TOT no. 2

TOT no. 3

TOT no. 4

TOT no. 5

TOT no. 6

TOT no. 7

TOT no. 8

TOT no. 9

TOT no. 10

Service book´s scanned copy is requested with each applied claim report

Upload a scanned copy

Reklamované díly

Date code

Part / Model No.

Customer part No.

Description

Qty.

Less restocking -20%

Total

Reason for material being returned

1. Overshipment or misshipment, or restocking (REQUIRES PRIOR APPROVAL)

Customer P.O. No.

ADAST Inv. No.

Total Received

Sales Order No.

Date

Total Scrapped

2. Product Failure during operation (give description)

3. Warranty Determination

Factory Service

Repair

4. Other

Return to factory approved by

Explanation / Special Instructions