Surname:*

First name:*

Telephone

Mobile phone*

Fax

E-mail*

Country*

_____________________________________________________________________________

Dealer name*

Dealer representative

(your contact person in the dealership) _____________________________________________________________________________

Vehicle type (e.g. S 350 or Viano)

Model year

Purchase date

Plate number

Chassis number

_____________________________________________________________________________

Complaint type*

e.g. After Sales Passenger Cars

Complaint details*