Customer Contact for Service

CONTROL SYSTEM - SERVICE CALL / PHONE SUPPORT
Date

MonthDayYear
Date
Do you have an Active Service Contract with Mercer-Zimmerman?*
ACTION ITEM REQUESTED*
NOTE: CALL BACK (Phone Support/Evaluation) — SITE VISIT (requires billing contact information be provided)
SYSTEM TYPE NEEDING SERVICE*
Hold Ctrl key while clicking to select multiple Systems (if DMX Fixtures or Other is selected, please provide details in the Description of Issue field.)
Service Contract/Project # if available
Will be listed on your Service Contract Proposal
CUSTOMER / JOB NAME*
SITE ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
SITE CITY*
SITE STATE*
State
SITE ZIP CODE*
SITE PHONE NUMBER*

Area CodePhone Number
SITE CONTACT *

First NameLast Name
SITE CONTACT EMAIL*
example@example.com
DESCRIPTION OF ISSUE*
Provide a description of your issue(s).
COMPANY NAME (for billing)*
BILLING CONTACT (ACCOUNTS PAYABLE)

First NameLast Name
BILLING ADDRESS

Street Address

Street Address Line 2

CityState

Zip Code
BILLING CITY
BILLING STATE
State
BILLING ZIP CODE
BILLING EMAIL
example@example.com
BILLING PHONE NUMBER

Area CodePhone Number
SERVICE REQUEST TO BE EMAILED TO:
example@example.com
Person Submitting Service Request*
MERCER-ZIMMERMAN CONTROLS CONTACT NAME

Name of Mercer-Zimmermanyou have been in contact with (If applicable)
Should be Empty:

CONTROL SYSTEM - SERVICE CALL / PHONE SUPPORT