Account Holder

Which Service/s do you require?

Required Service/s *

DEMONSTRATION

TRAINING

SERVICE

REPAIR

I have a Service & Breakdown Package *

Yes

Request Submission

Requestor Name: *

Requestor Email: *

Requestor Phone: *

Account Number: *

Account Name: *

Service & Breakdown Order number *

Numatic Sales Rep (if applicable):

P/O Number (Invoice purposes): *

If you have an upper limit for the value of this service, please leave details in the Additional Information section below

Provisional Date & Time Requirement

Please provide two provisional date’s and time’s for your request:

Date & Time 1:

Date: *

Time: *

Date & Time 2:

Date: *

Time: *

Trainee Candidates

Please leave trainee’s full names for certificate purposes below:

Candidate 1: *

Candidate 2:

Candidate 3:

Candidate 4:

Candidate 5:

Candidate 6:

Candidate 7:

Candidate 8:

Site/Location of Machine/Breakdown and on-site contact

We can only visit at a UK mainland location. Please provide correct address.

Company: *

Address Line 1: *

Address Line 2:

Address Line 3:

City: *

County: *

Post Code: *

Please give details for who we should call and their contact number when we arrive below.

On Site Contact: *

Contact Phone: *

Machine/Breakdown Details

Please answer all questions accurately and in full.

The voltage information and serial number can be found on the rating sticker of your machine.

You can add up to 4 machines that require attention at the same location. Please supply as much information as possible regarding the fault/s as this will assist us in servicing your machine/s

Machine: *

Unsure which machine? View the range here (opens in new window).

Machine Voltage: *

Serial Number: *

Your serial number will be on the rating label on your machine just below the barcode (Older machines may not have the bar code). It will comprise of 9 digits exactly and will be numerical. Please enter your serial number carefully as we will use this to confirm the details of your machine.

Machine Fault/Service/Training: *

Additional Machines:

Expand this section to add additional machines

Site Access/Parking

Please be accurate with regards to parking details, agents have large machines to unload and manoeuvre with possible tail lift on van.

On site parking available? *

Yes

OtherOther

if No please call 01460 269 478 / If Other please specify.

Parking Details:

Access for large van? *

Yes

NoNo

If No please specify additional detail or call 01460 269 478.

Security Clearance Needed? *

Yes

Times access available: *

To assist us in ensuring our engineer does not arrive at an inconvenient time, please give details on any time periods site access would not be granted. For example:
"Mondays - 10.00-12.00"
"Tuesday 20th Sept - 15.00-17.00"

Additional Information:

Supporting Documentation

Attach photo’s, correspondence and other below

File Upload

Maximum upload size: 128MB

Invoice Address:

Email Address: *

Company: *

Address Line 1: *

Address Line 2:

Address Line 3:

City: *

County: *

Post Code: *

Account Holder Terms and Conditions

Service charges - in warranty

If the claim is covered under the terms of the warranty, any parts required will be supplied and fitted free of charge. However, if the claim is found to be the result of fair wear and tear, neglect, accident, improper storage, misuse or abuse, the repair will be deemed out of warranty and appropriate charges applied.

Service charges

One call-out fee covers work at one site only. Please ensure multiple machines are gathered into one area or a secondary call-out fee may need to be applied.

Note: Discounts will apply to parts only.

Our agent can only assess and work on the machines requested.

If the agent cannot park near the site to perform the requested service on the day an aborted charge may apply.

If you require an estimate or any list prices of parts to be fitted, please request these from the engineer.

I have read and understood the above.

Account Holder Request Form