Imię i nazwisko kupującego .....................................................................................................................................................................................

Adres korespondencyjny .........................................................................................................................................................................................

Numer telefonu............................................................................................................................................................................................................

Adres e-mail..................................................................................................................................................................................................................

Data nabycia towaru.................................................................................................................................................................................................

Nazwa towaru..............................................................................................................................................................................................................

Numer zamówienia....................................................................................................................................................................................................

Numer faktury..............................................................................................................................................................................................................

Dnia..................................została stwierdzona wada towaru polegająca na: 

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Data i podpis

Formularz prosimy wydrukować i dołączyć do reklamowanego towaru wraz z dowodem zakupu.