SERVICE REQUEST FORM

Step 1: Contact Information

First name

Last name

Email

Best Phone Number

Step 2: Company Information

Business Address

Business Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Step 3: Machine Information

Machine Type

Make of Machine

Model of Machine

Machine Serial Number

Location of Machine

Step 4: Service Issues

Select All That Apply

Coin Jammed

Rejecting Coins

Dollar Jammed

Rejecting Dollars

Keeping Dollars

Keeping Change

Not Giving Any Change

Giving Incorrect Change

Selection Not Working (Clarify Below)

Display Reads "Make Another Selection"

Frozen Soda

Machine Not Cooling

Machine Has No Power

Noisy Machine

Light Bulb Burned Out

If "Selection Not Working" Enter Selection #

If Product Not Dropping Down Enter # or Name

Step 5: Additional Details

Please Specify Any Additional Details or Comments Below

Thank You for Submitting, Someone will be in contact soon!

MAIN OFFICE

W184 S8372 Challenger Dr

Muskego, WI 53150

262-679-1328

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