Request for Service -

Date of Request*
MM slash DD slash YYYY
Emergency Service Request*
- No, This is NOT an Emergency
- Yes, This is an Emergency
Please note that selecting "Yes" will change the billing rate from our Normal Rate to our Emergency Hourly Billing Rate. There is a 2 Hour Minimum on all Service Tickets
Customer / Business Name*
Contact Phone*
Contact Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Description of Issue(s)*
Please be as detailed as possible to help the technician with determining what he will need to bring with him.
Consent*
I Agree

By submitting this ticket I acknowledge that a Service Ticket will be created and I agree to all Service Terms listed below

- 2 Hour Minimum billing rate, Unless otherwise discussed
- $115/hr Regular Rate, $225/hr Emergency Rate
- All Service Requests are to be COD, Unless other arrangements have been approved by Synergy Management