Name
*
House Address
*
Ghana Post Address
Region
*
Select Region
Ahafo
Ashanti
Bono
Bono East
Central
Eastern
Greater Accra
Northern
North East
Oti
Savannah
Upper East
Upper West
Volta
Western
Western North
City
*
*
Mobile
Phone
Email:
*
Date of Purchase
*
Pending Fault?
*
Select Yes / No
Yes
No
Reported Fault
*
Select Yes / No
Yes
No
Date of Report
*
Condition of Item
*
Invoice Number
*
*
Brand
Select Product Brand
LG
Forbes
Orient Electric
Bruhm
Philips
Tamashi
Nasco
Panasonic
Product Type
*
Select Product Type
Television
Home Entertainment
Washing Machine
Microwave
Gas Cooker
Domestic Appliance
Air Conditioner
Freezer
Refrigerator
Beverage Cooler
Home Appliance
Kitchen Appliance
Personal Appliance
Product Name
*
*
Model Number
Serial Number
*
Warranty Status
*
*
Model Number
*
Serial Number
*
Warranty Status