Elite Appliance Delivery/Installation Form
Questions? Text us at 808-478-2833 or email us at info@eliteapplianceinc.com
Point of Contact Info & Job Address
Point of Contact will be the primary contact for scheduling and any communication on the day of appointment.
First and Last Name
*
Point of Contact First and Last Name
Phone #
*
Point of Contact Phone #
Format: (000) 000-0000.
Email Address
*
Point of Contact Email Address example@example.com
Job Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Info
Only required if different than the info listed above
Billing Info
If the billing information is different, please include the same details requested above from the “Point of Contact Info & Job Address” section. Note: If you complete the billing section, we’ll still assume the name, phone number, and email listed under “Point of Contact Info & Job Address” are the main contact for scheduling and any day-of communication—unless you specify otherwise. If someone else should be the point of contact, please let us know here.
Job Details
What services are needed? Check all that apply
*
Delivery
Installation
Removal: un-install existing appliance
Haul Away
Where did you purchase your appliance(s) from?
*
Ferguson
PHAD (Pacific Home & Appliance Distribution)
Coastal Appliance Co.
Other
Who is your Coastal Appliance sales representative?
*
Derek Choi
Rebecca Khani
Sierra Khani
John Medrano
Other
Who is your PHAD sales representative?
*
Herman Nillos
Leslie Tokunaga
Jeff Schriber
Randall Iwaishi
Other
List company name & sales representative
*
If delivery is needed, please include pick up address & all necessary pick up info.
Who is your Ferguson sales representative?
*
Hanne Kinoshita
Coleen Whiting
AJ Pearson
Other
List sales representative
*
Do you have steps?
*
Yes
No
Are your steps located inside or outside?
*
Inside
Outside
Both
How many steps?
*
Appliance Model Number(s) - List them here or you can attach a copy of your order below. *PLEASE NOTE: WE CANNOT PROVIDE A QUOTE WITHOUT THE MODEL NUMBER(S).
List any additional info here
Attach a copy of your order
Browse Files
Drag and drop files here
Choose a file
Other relevant pictures, videos, and documents can also be uploaded here.
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of
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