1-866-466-7527

DispatchTicket@Buchanan.com

Field Service Request

Contact Information

Company Name*

First Name*

Last Name*

Email*

Phone*

Customer Ticket Number

PO Number

Site Information

Name of Location*

Location Number

Onsite Contact*

Location Phone*

Location E-mail

Alternate Contact

Alternate Phone

Address*

Address Continued

City*

State / Province*

Zip*

Country*

Equipment Type*

If other:

Equipment Manufacturer

Model No.

Serial/Asset No.

Service Request

Select Priority Level*

Appointment Date (between)

Appointment Date (exactly on)

Please provide a full description of the problem*

Special Instructions

Attachments