Free maintenance request form 13
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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:
.