Service / Service form
COMPLAINT
Please send by fax to: +49 44 71 - 96 64 48 50 or by e-mail to: service.en@derby-cycle.com
To
Partner no.
Please fill out completely.
Derby Cycle Werke GmbH SiemensstraĂ&#x;e 1-3
Partner name/company
49661 Cloppenburg / Germany
Address first line
LA TE
Important:
Town, postcode
Delivery note no.
Telephone
Model
Fax
Item no. (if known)
Factory order no. (6 digits) (silver sticker on down tube)
Date/signature
Purchase date (Please attach customer’s proof of purchase!)
Stem
Seatpost
Would you like someone to call you back? yes
no
Have you sent us photos of the damage via e-mail?
MP
Damage in transit Damage under warranty Component failure in safety-relevant components Frame Fork Brake Handlebars
(service.en@derby-cycle.com) yes
no
Designation of defective component Description of fault Replacement
Order number
yes
no
yes
no
yes
no
yes
no
yes
no
TE
You receive:
in one shipment
Goods are available for collection (will be disposed of after 3 weeks)
If rejected:
Return material
Scrap
Invoiced
Service
obtained?
Other: Cost estimate