Repair Request Form

                                       M.J. Friedl & Associates, Inc.

                                          Repair Request

Date:

 

Send Equipment to:

M.J. Friedl & Associates, Inc.

2900 Love Point Road

Stevensville, MD  21666

410-604-1079

Attn: Repairs

 

Describe Problem/Comments Concerning the Unit: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Your Return/Billing Address:

Company Name: ______________________________________________________________________

Street or PO Box: ______________________________________________________________________

City:____________________________________________ State______________ ZIP:________________

Contact Name:_________________________________________________________________________

Contact Phone/Email:___________________________________________________________________

 

*** Need an Estimate prior to repairing? ***

YES                                    ☐NO

Your Equipment Information:

Type/Manufacturer: ____________________________________________________

Model: _______________________________________________________________

Serial#: _________________________ 

PO#________________

CC Number_________________ Exp. Date ______________ Sec#______ Billing Zip __________