versa INSERTO SEAT DOMINO Series Product Technical Specification page 20

Annex 1
Clinical Professional / Authorised Dealer:_________________________________________
Address:________________________________City:______________________________
State:_______Post Code#:_____________tel:__________________fax:_______________
Base:_____________________________________ Serial #:_________________________
Versa system:__________________________________ Serial #:_____________________
Order Details: Invoice #_______________________________Date: __________________
Shipping Doc. #:__________________________________ Date: ____________________
Malfunction: ________________________________________________________________
___________________________________________________________________________
_________________________________________________________________________
Component to replace : ____________________________________Quantity: ___________
Note:_____________________________________________________________________
_________________________________________________________________________
Cause of Intervention: _______________________________________________________
________________________________________________________________________
Component to replace: _______________________________________________________
Related to: ________________________________________
Quantity:__________
Note :______________
(in case of maintenance please specify if the failure of the components is total or partial)
_____________________________________________________________________________________
N.B. All unauthorized written interventions will void the CE mark
To be sent to the producer within 24 hours after the request of intervention to the fax +39 – 0831 - 730739