DVL Product Complaint

Yang Terhormat Bapak / Ibu Konsumen Darya-Varia

Demi kemudahan kami untuk melakukan investigasi terhadap keluhan Bapak / Ibu, mohon kerja sama Bapak / Ibu untuk mengisi informasi pada formulir dibawah ini:

An Honored Mr. / Ms. Consumer of Darya-Varia,

In order to investigate your complaint, we would like to appeal your cooperation to fill up the information in this form as below:

Detail Pelapor / Reporter Detail

Nama Pelapor / Reporter Name *

Harap diisi / This field is required

Nomor Ponsel / Mobile Phone Number *

Harap diisi / This field is required

Alamat Domisili / Domicile Address *

Harap diisi / This field is required

Alamat Email / Email Address *

Harap diisi / This field is required

Usia / Age *

Harap diisi / This field is required

Jenis Kelamin / Gender *

Harap diisi / This field is required

Detail Konsumen / Consumer Detail

Sama dengan pelapor

Nama Konsumen / Consumer Name *

Harap diisi / This field is required

Nomor Ponsel / Mobile Phone Number *

Harap diisi / This field is required

Alamat Domisili / Domicile Address *

Harap diisi / This field is required

Alamat Email / Email Address *

Harap diisi / This field is required

Usia / Age *

Harap diisi / This field is required

Jenis Kelamin / Gender *

Harap diisi / This field is required

Informasi Produk / Detail Product

Nama Brand / Brand Name *

Harap diisi / This field is required

Nama Produk / Product Name *

Harap diisi / This field is required

Nomor Batch / Batch No. *

Harap diisi / This field is required

Tanggal Manufaktur / Mfg. Date *

Harap diisi / This field is required

Tanggal Kedaluwarsa / Exp. Date *

Harap diisi / This field is required

Keluhan / Complaint

Harap diisi / This field is required

Pembelian / Purchase

Tanggal Pembelian / Purchase Date *

Harap diisi / This field is required

Toko Online / Online Store

Harap diisi / This field is required

Nama Toko Online / Online Shop Name

Harap diisi / This field is required

Apotek / Pharmacy

Nama Apotek / Pharmacy Name

Harap diisi / This field is required

Alamat Apotek / Pharmacy Address

Harap diisi / This field is required

Supermarket / Supermarket

Nama Supermarket / Supermarket Name

Harap diisi / This field is required

Alamat Supermarket / Supermarket Address

Harap diisi / This field is required

Lainnya / Other

Keterangan / More Information

Harap diisi / This field is required

Alamat / Address

Harap diisi / This field is required

Bukti Lampiran (Foto Produk) / Attachment (Product Photos) *

Harap diisi / This field is required

* Gambar harus jelas
* Maksimal 3 file
* Maksimal total file 5 MB