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The warranty claim

Place, date *

Data of the claimant:

Name *

Taxpayer Identification Number (TIN) *

Address *

Place *

Postcode *

Concerns:

Name of device concerned *

Serial number *

Description

The equipment of:

The ambulance make *

Model *

Vehicle Identification Number (VIN) *

Contact person:

First name and surname *

Telephone number *

E-mail *

Comments:

Comments

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