SUMMARRY

Full name:

{name-1}

Email:

{email-1}

Phone number:

{phone-1}

Date of purchase:

{date-1-day}{date-1-month}{date-1-year}

Store of purchase name and location:

{text-4}

Delivery address:

{text-1}

Request type:

{select-1}

Model number:

{text-2}

Serial number:

{text-3}

Description of damage:

{textarea-1}

Proof of purchase:

{upload-1}

Photos and/or videos of faulty/damaged part:

{upload-2}