1

Customer reference. (Claim no.):

2

Item number:

3

Invoice number:

4

Number of defective items:

5

Number of delivered items:

6

Heat No. (Cast items):

7

Requirements / Specification:

8

Observation:

9

Non Conformance:

10

(Drawing, Photo):

11

Repaired by customer:

12

Repaired by IPL:

13

Delivery of new item(s):