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       Customer Name     
(or Organization Name)
: *
Contact Person Name  : *  
Customer Address1 : *
Customer Address2 :     
Contact No : *  
Mobile No : *    
City : *    
Nearby major City name :       
State : *    
Email ID : *    (Please enter valid Email id. A mail will be send to this email id)
Product Category : *    
Machine Serial Number : *  
Date of purchase : *
   
Problem description : *    (Write brief description of the problem observed in the machine)