In­ter­ven­tion form

• Com­pany*

• Con­tact per­son*

• Ad­dress*

• ZIP / City*

• Phone num­ber*

• E-mail*

• Tick the box if the place of in­ter­ven­tion is dif­fer­ent from the place of your com­pany :

Device Loc­a­tion (To be com­pleted if the loc­a­tion of the in­ter­ven­tion is dif­fer­ent from the primary ad­dress)

• Com­pany*

• Con­tact per­son*

• Ad­ress*

• ZIP / City*

• Phone num­ber*

• E-mail*

• Device brand*

• Ref­er­en­ce

• Seri­al num­ber*

• Date of pur­chase

• War­ranty

• Yes

• De­scrip­tion of the break­down*

• Notes

• Fields marked with * are re­quired. The above in­form­a­tion is only trans­mit­ted to GMG Sup­ply SA and is con­fid­en­tial.