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Content
Maintenance/Repair Request Form
Use this form to report repair or maintenance needs.
Employee Name
Employee Number
Employee Email
Employee Phone Number
Department/Area
Supervisor Name
Machine/Vehicle/Unit Name
Machine/Truck/Unit Exact Location
Describe FULLY the maintenance need/repair request:
Yes
No
Yes
No
Yes
No
Has the supervisor or manager in that area been notified of the
maintenance or repair need?
Is this repair request URGENT?
Is the maintenance or repair request due to an accident or safety
concern?
Employee Signature
Report Date
*Complete the Maintenance/Repair Request Form and return it to the Maintenance
Department. Be sure and fill your contact information above so we can keep in
contact with you regarding your request. If there are any questions regarding this
form or request please contact:
.