Form N5 –Guarantor
Manufacturer: UBS Cool-B, LLC
“Refrigeration Equipment Plant”
309255, village Novaya Tavolzhanks, w/o No. Pionerskaya
Str., Belgorod region, Shebekinsk district, Russia
Identification No. 3120083886
Series В
Tear-off coupon
For commissioning within months of
warranty period
Filled by the Manufacturer (Seller)
Device name in accordance with specification, brand
Factory No. Date of manufacture
(surname, first name, patronymic of the responsible person of the manufacturer (seller)) (signature)
Stamp here
Filled by the Executant
Executant
(Company, organization name, legal address)
Date of warranty claim
(Year, month, date)
(Surname, first name, patronymic of the responsible person of the Executant) (Signature)
Stamp here
Signature of the consumer who confirms
the implementation of commissioning works
(Signature, date)
The tear-off counterfoil for maintenance during months of warranty
period.
Series В N
Executant
(Company, organization name, legal address)
Withdrawn
(Year, month, date)
(Surname, first name, patronymic of the responsible person of the Executant) (Signature)
Stamp here
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