Names and Surnames or Business name
Document type —Please choose an option—Foreigner CardDNIRUC
Document number
Address
Phone Number (prepend country code)
Email
Claim Type Claim (Disconformity with the product or service)Complaint (Discomfort regarding customer service)
Date of Incident
Price Paid ($)
Response you received from the service provider
Detail of the product or service
Details of the claim or complaint
I declare to be the owner of the content of this form, stating under sworn statement the facts described in it.
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