QR CUSTOMER CONTACT FOR SERVICE
Date
-
Month
-
Day
Year
Date
Do you have an Active Service Contract with Mercer-Zimmerman?
*
Yes
No
ACTION ITEM REQUESTED
*
CALL BACK REQUEST
SITE VISIT REQUEST
NOTE: CALL BACK (Phone Support/Evaluation) — SITE VISIT (requires billing contact information be provided)
SYSTEM TYPE NEEDING SERVICE
*
WATTSTOPPER
CRESTRON
ETC (ELECTRONIC THEATRE CONTROLS)
COOPER CONTROLS
ILC (INTELLIGENT LIGHTING CONTROLS)
ENCELIUM
SYNAPSE
DMX (PROVIDE DETAILS IN DESC. OF ISSUE SECTION)
Service Contract/Project # if available
Will be listed on your Service Contract Proposal
CUSTOMER / JOB NAME
*
SITE ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SITE PHONE NUMBER
*
-
Area Code
Phone Number
SITE CONTACT
*
First Name
Last 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 Name
Last Name
BILLING ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
BILLING EMAIL
example@example.com
BILLING PHONE NUMBER
-
Area Code
Phone Number
SERVICE REQUEST TO BE EMAILED TO:
example@example.com
Person Submitting Service Request
*
End User
Contractor
Distributor
MZ Associate
MERCER-ZIMMERMAN CONTROLS CONTACT NAME
Name of Mercer-Zimmerman
you have been in contact with (If applicable)
Upload applicable photos/videos
Browse Files
Cancel
of
Request Type
Please Select
Service Request
Follow Up
Submit
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