Warranty Application Date of Service Call* Name* Phone* Email* Address* City* US State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Zip Code* Technician Company Phone Address City US State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Zip Code HVAC/R Unit Number* Serial Number* Numerical Rating of HVAC/R Unit Condition at Time of Servicing* 1 = Excellent 2 3 4 5 6 7 8 9 10 = Bad Visual check of unit condition. Is there evidence of increased corrosion since the last service maintenance call?* Yes No Coil/Fin area cleaned with MicroKleen PLC-1 (diluted 1:20)* Yes No Tap Water Hose Rinsed* Yes No Visual Check Of Unit Condition* Yes No Dated & Signed Unit Decal Recording Service Call* Yes No Additional Notes Send
