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1. IDENTIFICACION DEL USUARIO O TERCERO LEGITIMADO:
* NOMBRE O RAZON SOCIAL:
*
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CORREO ELECTRONICO:
*
*
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TELEFONO - CELULAR:
*
*
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DOMICILIO:
*
*
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TIPO DE DOCUMENTO:
*
*
DNI
CARNET DE EXTRANJERIA
C.E.
LIBRETA MILITAR
PASAPORTE
RUC
Nº DE DOCUMENTO:
*
*
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3. LUGAR DE ORIGEN DEL RECLAMO:
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DETALLE DEL RECLAMO:
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*
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4. AUTORIZO NOTIFICACION DEL RESULTADO DEL RECLAMO AL E-MAIL CONSIGNADO (MARCAR):
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SI
NO
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