Request for On-Site Service

Sullair Corporation Tel: 219-879-5451

Service Department Toll Free:1-888-SULLAIR

1625 E. 2nd St.

Michigan City, IN 46360 Email:

When requesting on-site services, please fill out this form and e-mail () or fax to (219-878-4206) Sullair Service Department.

Customer Information Distributor Information

Company Name
P.O. Number
Address
City
State
Zip
Person Requesting Service
Point Of Contact
Phone Number
Fax Number

Sullair Equipment Information:

Model Number
Serial Number
Air End Serial Number

Personal Protective Equipment Required: (Check all that apply)

Arc Flash Protection*Hardhat Safety Glasses Safety Shoes Face Protection

Goggles Ear Plugs Respirator* Gloves* Clothing*

Air Monitor* Nomex Suit*

* describe in detail below what type

Description of Problem/Services Needed: (attach photos or sketches if available)

Desired Dates Of Service:

Start Date:
Start Time:

Print Name Date

2/1/2011