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Form Warranty in house

Nama :
…………………………………………………………………………………………….

No telp :
…………………………………………………………………………………………….

Email :
…………………………………………………………………………………………….

Tmpt & tgl pembelian :


…………………………………………………………………………………………….

Order no :
…………………………………………………………………………………………….

Frame : ……………………………………………………… harga :……………………….

Lensa : ……………………………………………………… harga :………………

Ukuran : R/

L/

Total :………………………………………………………………………………………………..

Reason pengklaiman : ………………………………………………………………………………………………

………………………………………………………………………………………………….

Tmpt & tgl pengklaiman : …………………………………………………………………………………………

Order no : ………………………………………………………………………………………

Jenis klaim : Frame & lensa

Frame only

Lensa only

Frame : ………………………………………………………… harga :…………………..

Lensa : ……………………………………………………….. harga :………………….

Ukuran : R/

L/

Total :

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