Registro Reclamos y Sugerencias FIDEM

Fecha: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Hora: *This question is required.

ID Solic. *This question is required.

1. Número de documento de identidad: *This question is required. ej: Cédula

2. Datos: *This question is required.

Nombres: *This question is required.

Apellidos: *This question is required.

Teléfono domiciliar: *This question is required.

Teléfono celular: *This question is required.

Correo electrónico: *This question is required. This question requires a valid email address.

4. Fecha del incidente: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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4. Punto de Atención: *This question is required.

5. Moneda: *This question is required.

5. Monto: *This question is required.

5. Marca del bien: *This question is required.

6. Comentarios: *This question is required.

7. Tiende a bien recibir respuesta vía: *This question is required.