Repair Request Form

Litchfield Park Pool Service LLC
4900 N Litchfield Rd Ste A * Litchfield Park AZ 85340

Repair Request Form

Current Date*

Date

Customer Information

Name*

First NameLast Name

Would we find you in our database because we have been to this property before or have made a major purchase such as a cleaner, pump, motor, etc.?*

YesNo

Do you have a home warranty that covers the cost of repairing or replacing pool equipment breakdown or repair? Performing unauthorized repairs could void your home warranty*

YesNo

Best Phone Number*

Please enter a valid phone number.

Alternate Phone Number

Please enter a valid phone number.

Email*

example@example.com

Confirm Email*

example@example.com

How do you prefer to be contacted - text or e-mail?*

example@example.com

Pool Address

Street Address

Street Address Line 2

CityState

Zip Code

Describe Trouble

Issue with motor, pump, in-floor cleaning system, salt cell, heater, or other trouble...

What issues are you having?*

	Problem Description
1
2
3

Equipment Information

	Manufacturer	Model/Part No.	Item Description	Color
1
2
3

Upload photos of the equipment that needs repair

Was the equipment listed above been repaired within the last 30 days for the same issue?*

YesNo

Do you have dogs?*

YesNo

Do you have a lock on your gate?*

YesNo

What subdivision are you in blank ?

What are your major crossroads blank ?

Are you in a gated community?*

YesNo

Do you want to be called BEFORE THE REPAIR TECHNICIAN HEADS OUT?*

YesNo

Do you want to be there WITH THE REPAIR TECHNICIAN AT THE TIME OF REPAIR?*

YesNo

Payment method - Payment is Due Upon Completion of the Work *

The card on file will be used unless other arrangements have been made prior to the work being completed.

Mailing Address *

Street Address

Street Address Line 2

CityState

Zip Code

Do you have any special instructions?

Notes and Reminders

Once we receive this form submission, we'll call you over the phone to make sure that we have the correct information.

Accounts due beyond 10 days are subject to a $25.00 fee to pursue payment and/or submitted to an outside collection agency.

File Upload

Please verify*