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A COMPLÉTER PAR L'ACHETEUR / TO BE COMPLETED BY THE
BUYER
/ VOM KÄUFER AUSZUFÜLLEN / IN TE VULLEN DOOR
DE KOPER
Nom / Name / Name / Naam
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Prénom / First Name / Vorname / Voornaam
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Adresse / Adress / Adresse / Adres
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Téléphone / Phone / Telefon / Telefoon
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
e-mail
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
À
RENSEIGNER IMPÉRATIVEMENT PAR LE CONCESSIONNAIRE
E
-SOLEX / TO BE IMPERATIVELY FILLED OUT BY THE
E
-SOLEX DEALER / UNBEDINGT VOM E-SOLEX
HÄNDLER ANZUGEBEN / INFORMATIE DIE MOET WORDEN
VERSCHAFT DOOR DE CONCESSIEHOUDER VAN E
-SOLEX
N° de série du véhicule / Series num. of the vehicle
/ Seriennummer des Fahrzeugs / Serienummer van
het voertuig
VREE _ _ _ _ _ _ _ _ _
N° de série de la batterie / Series num. of the bat-
tery / Seriennummer des Akkus / Serienummer van
de batterij
_ _ _ _ _ _ _ _ _ _ _ _
Date de 1
ère
mise en circulation / 1
st
date of use /
Tag der Erstinbetriebnahme / Datum van de eerste
ingebruikname
_ _ / _ _ / _ _ _ _
Cachet du Concessionnaire e-Solex / e-Solex dealer stamp /
Stempel des e-Solex Händlers / Stempel van de e-Solex Concessiehouder
18


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