ORDER – MD GUARD

Customer information (MD GUARD)

Name, Surname / Name of company *

Personal code / Company code *

VAT code

Contact number(s) *

Address *

E-mail address

Type of Payment *

Vehicle

Vehicle body number

Registration number

Manufacturer *

Year of manufacture *

Color *

Model *

Insurance company (CASCO insurance holders)

Leasing company

System unit

Frequency of service payments *

Other security equipment fitted

If the vehicle is fitted with any other security equipment, please fill in the following.

Brand

Workshop

Additional information

Name, Surname of an authorized representative *

Email address of the authorized representative *

I confirm that the information provided in this form is true, complete and accurate. *

I confirm that the information provided in this form is true, complete and accurate.

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