Account Name:*

Requestor's Name:*

Requestor's E-mail Address:*

On-Site Contact Name:

Phone Number:

Do you have a Purchase Order for this request or will you be paying by Credit Card?

Credit Card
Purchase Order

PO Number (if applicable):

What is the address where the work needs to be performed?

Is the billing address different?

Do you have/need a work order number? If so, what is the number?

Can you please tell us a description of the problem?

How urgent is the problem? (1 being "not incredibly urgent, get me scheduled" to a 5 indicating you need us there ASAP)

1
2
3
4
5

Do you have a Service Maintenance Agreement?

Yes
No

If not, are you interested in more information on a Service Maintenance Agreement?

Yes
No

If you do not have a Service Maintenance or other Service Agreement with us the standard service call charges will apply. The standard charges are $95 for the service origination and trip charge, and our labor rate is $95 per hour on site, with a one hour minimum.

Please check here that you acknowledge what the minimum charges will be.

Also, please understand that if you are sending this request after hours or on weekends, this request will not be read until the morning of the next business day. We have emergency service technicians on call 24/7/365. If you need a service call scheduled immediately please call 480-892-8688.