Customer

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Salutation:

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Firstname*:

Surname*:

Street*:

ZIP code*:

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Country*:

Phone:

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Email (for control)*:

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Inovice number for device purchase*:

Date of device purchase*:

Manufacturer*:

Type and model of device*:

Device name*:

Serial number / IMEI*:

Device price from invoice*:

Date of damage*:

Time*:

Where did the damage occur?*:

Who caused the damage?*:

How did the damage happen?*:

Description of damage*:

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