Large Appliance Service Inquiry

Name:*

First

Last

Address:*

Street Address City State / Province / Region Postal / Zip Code Country

Name of Condo Project (if applicable)

Suite or Unit Number (if applicable)

Concierge on site (if applicable)

Buzz or Gate Code (if applicable):

Phone-Area Code*

Area Code

-

Phone Number

Email:*

Your Primary Language*

Your Secondary Language (if applicable)

If we have to send out a spare part with Purolator, how would you like us to ship it:*

Signature required

If not available, no signature required and leave at front door

Did you*

Purchase for personal home use

First owner in new condo unit

Commercial Use

Name of Appliance Dealer:

City in which Dealer is located:

Purchase Date / Move in Date*

Proof of Purchase

If proof of purchase cannot be provided, please note the reason why:

Did you purchase an extended warranty?*

Yes

No

Brand of your appliance*

Liebherr

Gorenje

AEG

Porter & Charles

Model Number*

Serial Number*

Index or PNC Number

Description of Complaint or Malfunction*

Picture or video of damaged part or malfunction:

Picture of Serial Number/ ID Tag of your Appliance