1. Accept Decline
Accept Decline
□ check #
□visa □amex □mc □discover
card #
3 digit code #
signature:
wo agrmnt. INVESTMENT w agrmnt.
$
Total Due $
Name: www.anymechanicalcompany.com
Diagnostic Tasks Performed CUSTOMER INFORMATION
□ Evaluate Air Filter clean_______dirty________ Name:
COPY AND PASTE YOUR LOGO HERE
Certified Technicians ANY MECHANICAL COMPANY
Name:
Name: 12345 ANY STREET
Name: ANYWHERE, USA 12345
Maintenance Technicians OFFICE: ### - ### - ####
EMAIL:
□ Inspect Relays and Contactors yes_____ no_____ Email:
□ Check Amp Draw on Fan Motor amps_________
□ Check Amp Draw on Compressor amps_______ Equipment Location if Different
□ Clear Condensate Drain Line Address:
□ Clean Coil(s) indoor________outdoor_________ Address:
□ Tighten All Electrical Connections
□ Test Capacitors c1______c2______c3_______ Phone:
□ Inspect Refrigerant Piping
□ Clean Burners / Inspect Ignition Components
□ Clean Flame Sensor
□ Verify Cooling Performance td_______
□ Verify Thermostat Calibration
□ Verify Refrigerant Charge Required Repairs
□ Check Incoming Power volts_____1ph__3ph__
□ Clean Blower Wheel Suggested Repairs or Upgrades
□ Inspect Flue Exhaust Openings / Dampers
□ Inspect Combustion Air Openings
□ Leak Check Gas Line / Test Gas Valve Pressures
□ Inspect Heat Exchanger
□ Inspect Strip Heaters
□ Inspect Zone Valve (s)
□ Inspect Aqua Stat Limit / Pump Service Date (s)
□ Inspect Backflow Preventer Start: Terms
□ Inspect Relays and Contactors
□ Check Amp Draw on Blower Motor amps______
□ Inspect Expansion Tank / Air Separator
□ Inspect All Pumps End: Full payment due upon completion
□ Inspect All Piping and Loops
□ Inspect Low Water Cutoff
Material, parts and equipment are warranted by manufactures written warranty
only. Any labor provided by installing contractor named above is warranted for
## year (s), unless expressed in writing.
□ Inspect Gauge Glass Assembly
□ Verify Heating Performance and CFM_________
Payment Customer Signature Company Representative
□cash □check □credit card □debit card Sign Sign
Equipment Information
model#
I ______________________________ did authorize the above work and do attest
it is satisfactory completed. I agree that all material remains property of
contractor named above until final payment is received.
serial#
model#
serial#
$ Name:_________________________________________________________
Maint. Agreement Discount 10% $ Address:________________________________________________________
City:_________________State:___________________Zip:______________
Amount Received: $ Print Print
Referral Offer
______________________________ referred me to your company and with my
purchase of a new Comfort System please send
______________________________ a $100.00 gift card from
______________________________