Repair Request Form

Please fill out form below to request your Appliance repair service.
We will contact you to setup appointment! NOTE - we no longer service TV's.
Fields marked with * are Required

Customer's Information:
First Name*
Last Name*
Street Address*
City*
State*
Zip*
Phone Number*	(10 numbers only)
E-mail Address*
Product Information:
Brand *
Model Number *
Serial Number
Date of Purchase (if in warranty)	/ /
Symptom *
Additional Information
If you have any problems submitting this form please contact us immediately.