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Customer Number
Company Name
*
Contact Person
*
Street
*
Post Code / City
*
Telephone
*
Fax
Mobile
Email
*
Site Name / Project
Site Contact Person
Site Street
Site Post Code / City
Site Telephone
Site Fax
Site Mobile
Site Email
Preferred Date
Product (Pump Type)
*
Pumped Liquid
Product Number
Type, kind of sealing
Voltage
230V
110V
Year of manufacture
Information about pump failure and type of pump system
*
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Please download the Safety Declaration below and email it to
lechtech@iafrica.com