Product name: ………………………………………………………………. Gross price: …………………………………………….. Quantity: ………………………………………………….. Description of the product: …………………………………………………………………….. ………………………………………………………………………………………………………. Invoice/receipt number (if applicable): …………………………………………………….. Delivery address: ……………………………………………………………………………………….
Description of the issue:
Description of the defect and circumstances of its occurrence: ………………………………………………………………………………………………………. ………………………………………………………………………………………………………. ………………………………………………………………………………………………………. Date when the defect was noticed: …………………………………………………
Request:
Please select one of the following options: ☐ Replace the product with a defect-free one ☐ Repair the defect ☐ Price reduction ☐ Withdraw from the contract
………………………………………………. Date and signature (if the statement is submitted in paper form)
