Free maintenance request form 06
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Maintenance / Repair Request Form
Use this form to report repair or maintenance needs.
Employee Name

Employee Number

Department / Area

Supervisor Name

Machine / Vehicle / Unit Name

Machine / Truck / Unit Exact Location

Describe FULLY the maintenance need / repair request:

YES

NO

Has the supervisor in that area been notified of the
maintenance or repair need?

YES

NO

Is this repair request URGENT?

YES

NO

Employee Signature

Is the maintenance or repair request due to an accident
or safety concern?
Report Date