Sullair Corporation



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Request for On-Site Service

Sullair Corporation Tel: 219-879-5451

Service Department Toll Free:1-888-SULLAIR

1625 E. 2nd St.

Michigan City, IN 46360 Email: service.department@

When requesting on-site services, please fill out this form and e-mail (service.department@) or fax to (219-878-4206) Sullair Service Department.

Customer Information Distributor Information

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Sullair Equipment Information:

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Personal Protective Equipment Required: (Check all that apply)

Arc Flash Protection*Hardhat Safety Glasses Safety Shoes Face Protection

Goggles Ear Plugs Respirator* Gloves* Clothing*

Air Monitor* Nomex Suit*

* describe in detail below what type

Description of Problem/Services Needed: (attach photos or sketches if available)

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Desired Dates Of Service:

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Print Name Date

|      |2/1/2011     |

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