Order No.

WARRANTY REPAIR
REPORT FORM

COMPANY DATA OF THE PERSON

REPORTING THE REPAIR
Company name
Address

Tax Identification Number (NIP)

Contact person name
Phone No.

COMPANY DATA
- OF EQUIPMENT USER*
*if different from above
Company name
Address

Tax Identification Number (NIP)

Contact person name
Phone No.

EQUIPMENT MODEL Equipment model Factory No. Meter reading

FACTORY NO.
METER READING

Purchase date Invoice No.

PURCHASE DATE OF EQUIPMENT
INVOICE NO.

ASSUMED SCOPE OF THE REPAIR:

ADDITIONAL INFORMATION,
NOTES:

CLAIM HAS BEEN SETTLED:

………………….. …………………………………………………………….. ……………………………………………………………

Date Signature of the person reporting the repair Company stamp

Please send the filled in form to Airpol Ltd e -mail: serw is @airpol.com.pl
Przedsiębiorstwo Produkcji Sprężarek Airpol Ltd. ul. Nieszawska 15, 61-021 Poznań, Poland tel. +48 61 650 45 67; service +48 694 477 251