Service Request Form Are you in need of air conditioning or heating service? Please fill out the form below and an AccuTemp representative will contact you to set up an appointment within 24 hours.   About You Your Name: Company Name: Address: City, State, Zip: Home Phome: Day Phone: E-Mail Address: About Your System Do you Have a central air problem? Yes No Do you have a problem with central heat? Yes No What brand name is your system? Do you have a heat pump? Yes No Have you checked your fuses & breakers? Yes No Has your system been serviced in the past 12 months? Yes No Do you have a service preventative maintenance agreement? Yes No Would you like information on annual contracts benefits? Yes No Have you used AccuTemp in the past? Yes No Is your situation an emergency? Yes No Do you have a service contract? Yes No Where did you hear about AccuTemp? Real Yellow Pages Television Ad Referral The Clipper Search Engine The Atlanta's Choice Other: Please enter the time desired for your service: Date: Time:

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