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Service Request

Fill out all Information
Company Name
Contact Name
Shipping Address
City, State, Zip		City State Zip
Phone Number and Ext		Ext
Fax Number
E-Mail Address

Please Answer the Following Questions
Did you purchase the Machine from BusinessNeedz.com?		Yes No
What is the brand of machine purchased ?
What is the Model Number?
What is the Date of Purchase?
What Error Code is it Displaying? (If no code is displaying type "NONE")
Describe the Problem that you are having