Service Request

SERVICE REQUEST
Date of request*

MonthDayYear
Date
Contact Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Full Home Address
Email:*
example@example.com
Phone number:*
Service Requirement
If you are requesting service on one of Kim's Cozy Campers' rental units, please pick from the rental list below.

If you are requesting service on your own camper, please enter your vehicle details.
RV Year:*
RV Manufacturer:*
RV FULL Model:*
RV VIN:
Pick your Rental: Choose the Type; THEN chooses SPECIFIC Rental*
Specific Location of RV (ONLY enter IF different from above)
Location of RV (ONLY enter IF different from above)

Street Address

Street Address Line 2

CityState

Zip Code
Urgency level:*
Service type:*
Type of RV:*
If you selected other, Please Explain:
Description of problem:
Availability
Preferred time for service (check all that apply):

between 7 AM and 9 AMbetween 9 AM and 12 PMbetween 12 PM and 5 PMafter 5 PM
Preferred day of the week/weekend (check all that apply):

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
THANK YOU: Your request will be processed in the order it was received.
PAYMENT POLICY & AGREEMENT*
Autocompleted Address
Should be Empty:

SERVICE REQUEST