The back of the tear-off coupon
Filled by the Executant
Executant
(Company, organization name, legal address)
The number under which the device is taken for warranty
Repair reason
Name of the replaced part,
assembly
Date of repair
(year, month, date)
Executant’s
signature
(Surname, first name, patronymic of the responsible person of the Executant) (Signature)
Stamp here
Signature of the consumer confirming performance of works on warranty
repair
(Signature)
(Date)
The tear-off counterfoil for warranty repair during _______ months
of warranty period.
Series В
N 0
Executant
(Company, organization name, legal address)
Withdrawn
(Year, month, date)
(Surname, first name, patronymic of the responsible person of the Executant) (Signature)
Stamp here
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