Service Request Form YOUR REQUEST WILL BE ASSIGNED TO FIRST AVAILABLE APPOINTMENT. ALL APPOINTMENTS WILL BE CONFIRMED THE DAY PRIOR AND YOU WILL BE GIVEN AN APPROXIMATE TIME FRAME WITH A TWO-HOUR WINDOW.

*=required *Name:
*Address:
Nearest Major Cross Streets:
*Phone #:
Alternate Phone #:
Email Address:
*Manufacturer:	[select] Admiral Amana Electrolux Frigidaire General Electric Jenn-Air Kenmore Kitchenaid Magic Chef Maytag Whirlpool Other (please Specify)
*Appliance Type:	[select] Range Wall Oven Microwave/Hood Refrigerator Dryer Washer Dishwasher   * Gas     Electric
*Model Number:
Serial Number:
Date of Purchase:	** IF D.O.P. NOT AVAILABLE - PLEASE GIVE APPROXIMATE AGE. IF LESS THAN ONE YEAR OLD, MUST SHOW TECHNICIAN VALID PROOF OF PURCHASE/DELIVERY RECEIPT UPON ARRIVAL TO VERIFY MANUFACTURER'S WARRANTY
*Approximate Age:
Preferred Day of Week:	[select] Monday Tuesday Wednesday Thursday Friday Saturday YOUR REQUEST WILL BE ASSIGNED TO FIRST AVAILABLE APPOINTMENT. ALL APPOINTMENTS WILL BE CONFIRMED THE DAY PRIOR AND YOU WILL BE GIVEN AN APPROXIMATE TIME FRAME WITH A TWO-HOUR WINDOW. IF REQUESTING A SPECIFIC DAY/TIME
*Purchased at::	[select] Sears Pearsons OSH Lowes Best Buy Home Depot Other(Please Specify)
*Please Describe Problem: