Service Request Form

	(* required field)
Requested Service Date:		(dd/mm/yy)

Customer Information:
* Full Name:		* Address:
* City:		* State:	* Zip Code:
* Phone:		Fax:
Cell Phone:		* Email:

Equipment Information: (Please give as much information as possible)
* Make:		* Model:
Serial Number:		Voltage:
Phase:		* Location:
* Description of Problem:
	In order to reduce erroneous submissions, please enter the total of the two numbers below.
3 plus 5 =

141 Business Park Circle , Berkeley Springs, WV 25411 Toll Free (800) 866-6905 • Phone (304) 258-9023 • Fax (304) 258-9064

Copyright ©2011 Laundry Equipment Service, Inc - All rights reserved. Not responsible for typographical errors. Manufacturers part numbers and illustrations intended solely for identification purposes. We reserve the right to limit quantities. Prices subject to change without notice.
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