SERVICE REQUEST FORM

SERVICE REQUEST FORM
Contact Information
Customer Company *
Company Name
Contact Name *

First Name Last Name
Phone Number *

Country Code Area Code Phone Number
Email *
example@example.com
Shipping Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Address Type *

Residential Commercial
Delivery Specifications *

Liftgate Required Dock Access
Special Delivery Instructions
Contact name, number, delivery requirements, etc.
Hours of operation for delivery *
Billing Contact *

First Name Last Name
Billing Email *
example@example.com
Billing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Reseller *
Company equipment was purchased from.
Reseller Sales Person

First Name Last Name
Was this purchased within the past 12 months? *

Yes No
Date of Purchase

Month Day Year
Date
Order Number
Reseller order number
Proof of Purchase

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Receipt/Invoice required for warranty claims Cancel of
Form Completed by:
Product Details
Type of Equipment *
Maxi Miller, Mini Pump, etc.
Serial Number *
Serial number listed on Miller or Coating Pump
Product Number
Picote or Reseller product/part number
What was the power source for the equipment when you experienced the problem? *
i.e. Generator type, 110v, etc.
Other products that have been affected (if any)
Reason for Service Request
Describe the fault / what symptoms are being experienced? *

(Noise, shake, overheating, cable twisting, etc.) 0/500
Is this a recurring problem? *

Yes No
How many times has this problem occurred? *
Describe the job being performed when the fault appeared. *
i.e. Liner removal, coating, etc.
Which other Picote products (or other supporting products such as a generator) were used during the job? *
How long was the tool used for before the fault appeared? *
i.e. 30 mins, 3 hours, etc.
Has the tool or machine been used successfully before? *

Yes No
Estimated total usage of the tool / machine. *
Number of hours
Was the operator trained for the usage of the equipment? *

Yes No
If so, by which company?
i.e. Picote or Reseller Name
Date training was completed on.

Month Day Year
Date
Have you contacted your Reseller or Picote about the same problem before? *

Yes No
Which Company?
Contact name
Person you spoke with.
Have you asked for support from your Reseller? *

Yes No
Has repair been attempted already? *

Yes No
If yes, what was attempted?
Other remarks
Additional description of the issue.
Attach pictures of fault / equipment *

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SERVICE REQUEST FORM

Contact Information

Product Details

Reason for Service Request