Parts Request Form
Customer Name:
*
Date
*
-
Month
-
Day
Year
Date
Email:
*
example@example.com
Shipping Address for replacement part:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Warranty Claim?
*
Yes
No
Factory Warranty or Rebuilt Equipment?
*
Factory (Less than 3 years old since new)
Rebuilt Warranty through Midwest Laundries
Speed Queen/Huebsch Warranty?
*
Yes
No
Shipping address different from machine location?
*
Yes
No
Location of where machine is installed?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Model:
*
Serial
*
Installation Date:
*
-
Month
-
Day
Year
Date
Service Date:
*
-
Month
-
Day
Year
Date
Part Number:
Part Description:
*
Error Code or issue requiring attention:
*
Description of the repair process:
Please upload photos of defective part (REQUIRED FOR ELECTRONIC PARTS):
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Second Part to Add? (Disabled for Warranty Claims)
Yes
No
New Model/Serial?
*
Yes
No
Model:
*
Serial
*
Part Number:
Part Description:
*
Please upload photos of defective part (REQUIRED FOR ELECTRONIC PARTS):
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Third Part to Add?
Yes
No
New Model/Serial?
*
Yes
No
Model:
*
Serial
*
Part Number:
Part Description:
*
Please upload photos of defective part (REQUIRED FOR ELECTRONIC PARTS):
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Fourth Part to Add?
Yes
No
New Model/Serial?
*
Yes
No
Model:
*
Serial
*
Part Number:
Part Description:
*
Please upload photos of defective part (REQUIRED FOR ELECTRONIC PARTS):
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Fifth Part to Add?
Yes
No
New Model/Serial?
*
Yes
No
Model:
*
Serial
*
Part Number:
Part Description:
*
Please upload photos of defective part (REQUIRED FOR ELECTRONIC PARTS):
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Sixth Part to Add?
Yes
No
New Model/Serial?
*
Yes
No
Model:
*
Serial
*
Part Number:
Part Description:
*
Please upload photos of defective part (REQUIRED FOR ELECTRONIC PARTS):
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Seventh Part to Add?
Yes
No
New Model/Serial?
*
Yes
No
Model:
*
Serial
*
Part Number:
Part Description:
*
Please upload photos of defective part (REQUIRED FOR ELECTRONIC PARTS):
Browse Files
Drag and drop files here
Choose a file
Cancel
of
May we add $1.00 to your invoice as a donation to the LaundryCares Foundation?
Yes, please.
No, thank you.
Save
Submit
Should be Empty: