Service Ticket & Part Request Form
Service Performed By
*
James
Other
Request for Service Date
*
/
Month
/
Day
Year
Date Picker Icon
Date of Service Performed
*
-
Month
-
Day
Year
Date Picker Icon
Arrival
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Departure
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Company
Contact Name
*
First Name
Last Name
Contact Phone
*
-
Area Code
Phone Number
Contact E-mail
*
Additional Contact E-mail
example@example.com
Address
*
Street
Bldg/Ste/Apt
City
State / Province
Zip Code
Back
Next
Make
*
Canon
HP
Kip
Mutoh
Universal Laser
Xerox
Other
Model
*
Serial #
*
Meter A
*
Meter B
Meter C
Meter D
Services Performed
*
Call Status
*
Call Complete
Call Complete - Parts Requested for Additional Service
Incomplete - HARD DOWN
Incomplete - Parts Requested
Other
Services/Parts/Supplies Provided
Parts Request
Back
Next
Additional Equipment Serviced
*
NO
YES
Arrival
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Departure
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Make
Canon
HP
Kip
Mutoh
Universal Laser
Xerox
Other
Model
Serial #
Meter A
Meter B
Meter C
Meter D
Services Performed
Call Status (Additional Equipment)
Call Complete
Call Complete - Parts Requested for Additional Service
Incomplete - HARD DOWN
Incomplete - Parts Requested
Other
Services/Parts/Supplies Provided (Additional Equipment)
Parts Request (Additional Equipment)
Back
Next
Ship To
Warehouse
Customer
Other
Shipping Priority
Ground (3 - 5 days)
Other
Additional Notes
Service Account Type
*
Please Select
Burks In-House
Burks MPS Account
Time & Material
Pro-Services
Payment Type
Please Select
Burks Account
American Express
Discover
Master Card
Visa
Cash
Check
Check Number
Submit
Should be Empty: