| Nazwa firmy | .......................................................................................... |
| Ulica | .......................................................................................... |
| Kod, miasto | ......-........, ....................................................................... |
| Osoba kontaktowa | .......................................................................................... |
| Telefon kontaktowy | .......................................................................................... |
| Adres e-mail | .......................................................................................... |
| Nr Faktury zakupu | .......................................................................................... |
| Data zakupu | .......................................................................................... |
| Opis usterki | ..........................................................................................
.......................................................................................... .......................................................................................... .......................................................................................... .......................................................................................... .......................................................................................... |
| Tak / Nie | Czy dokonano ponownego uruchomienia systemu? |