Parts Order Form

Customer Name*

First NameLast Name
Customer Phone Number*

Area CodePhone Number
Customer Email Record
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Parts Order
Issue Date

DayMonthYearHourMinutesAM/PM Option
Brand*

Aussie PumpCleanicCleanstarCleanTechEurostarGBGhibliHaoTianHooverLichiLotcleanPacVacPolivacPullmanRocketWertheimOther
Supplier Company Name AP
Supplier Company Name CC
Supplier Company Name CS
Supplier Company Name CT
Supplier Company Name ES
Supplier Company Name GH
Supplier Company Name PV
Supplier Company Name VS
Supplier Full Name

First NameLast Name
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Product Information
Model
Serial Number
Color or Graphic
Item Name
Parts Require for Repair?

MotorPumpSwitchSwitch BoardBeltConnectionHoseWheelOther
Product Informaiton
Description of Products and Issue

Please briefly describe the issue you are encountering.0/500
Detail Photo

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Golden Brown ID2
It is under Warranty?

YesNo
Extra Parts Require for Repair?

MotorPumpSwitchSwitch BoardBeltConectionHoseWheelOther
Date Parts Received

MonthDayYear
Outcome of Service
Machine after repaire is fixed?

YesNo
Return Back to Customer?

Yes Send to CustomerNo Still in GB ShopWill Pick by CustomerFixed by Other MechanicCalled to Pick Up from StoreEmail to Pick Up from Store
Extra Details
Case Closed?

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Parts Order