Company Name:
Report Compiled By:
Position:

Company Name:
Site Address:
Contact Name:

Brecknell Product Code	Serial No(s)	Brecknell Invoice No(s) / Your PO No(s)	Date Installed / Sold to End User	Date Failed

Customer application of equipment:

Fault Description

Repeat occurrence?	Yes       No
Dates of previous occurrences of same fault along with claim numbers

Work Done To Resolve the Fault (Including name of Brecknell technician if already spoken)

Credit or Replacement Required?

Credit       Replacement

Part Number Required	Part Model & Capacity	Quantity Required

Additional Comments

Report made by:

E-mail Address (for Customer Copy):

Claim Number: Filled in by AWTX	BWR:
Customer Account Number:	Date Submitted: