Tool Repair Request Form

First Name     Last Name     Phone      (ex: 704-555-1212) Fax   Email   (ex: your.name@emailco.com) Address      City      State ** Please Select ** Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Federated States of Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma ON Oregon Pennsylvania Puerto Rico Palau QU Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming     ZIP      Select the closest Ellis Flooring Sales Location to you:  ** Please Select ** CHARLOTTE COLUMBIA GREENSBORO GREENVILLE RALEIGH RENTAL AND REPAIR CENTER

Tool Name      (ex: Electric Tacker) Manufacturer   (ex: Crain) Model Number   Problem Description      (please be as descriptive as possible) How will your tool arrive at our office for repair? ** Please Select ** DROP OFF NEXT DELIVERY PICKUP WILL SHIP     Check here to acknowledge you have read and understood the Tool Repair Agreement Check here if you require a work estimate before the repair is complete