Please Copy the 'Form' Below for Reporting OST and Warranty Calls

QMFMC002 WARRANTY / OST CALL ESCALATION REPORT

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Please complete this form for each

Warranty / OST call escalated to the Diebold Support Center.

Please complete all fields with as much detail as possible.

Thank you for your cooperation in helping us to better address your issues.

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Company Name: ______

Person reporting problem to Diebold Support Centre (Contact): ______

E-mail address: ______

Telephone Number: ______

Sales Order Number1 / Machine Type2 / Serial Number2 / Part Number / Part Description / Part Serial Number
(if available) / Quantity / Are The Parts Available For Return?
(Yes / No)
Symptom3
Problem Determination4
Resolution5
Time Frame6
Warranty YES / NO / OST YES / NO
Symptom
Problem Determination
Resolution
Time Frame
Warranty YES / NO / OST YES / NO
Symptom
Problem Determination
Resolution
Time Frame
Warranty YES / NO / OST YES / NO

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Ship to Address:

Company Name: ______

Location Name/Number: ______

Street Name: ______

City/Town: ______

Postal District: ______

Postal Code: ______

Country: ______

Contact Name: ______

Contact Telephone Number: ______

If this form is not completed accurately and completely, it could impact the delivery / processing of your warranty claim.

Notes:

1. Required if claiming for a defective service part that is within the service part warranty period.

2. Required if claiming for a defective part on a machine that is within the product warranty period.

3. What is the actual problem with the part / machine?

4. What action was performed to determine / prove the failure?

5. What fixed the problem – include part numbers and descriptions of parts used.

6. Period from installation to failure.

Confidential - For Internal Use Only

Printed Copies Uncontrolled - Unless Filled In -Verify Latest Version in Livelink