Invoice Date: P. O. Number: Authorization No: Hm. Ph.: Bus. Ph.: City: State: Dealer: Zip: Color: Date Complaint Noticed or Filed: Size: Date Requested: Requested By: Date Installed: Mfg. / Dealer. / Consumer: Invoice #: Claim Number: Consumer’s Name: Address: Manufacturer: Special Instructions: CONSUMER’S INFORMATION: PRODUCT INFORMATION: Quality Name: Date Installed: How did you hear about us?: COMPLAINT: Type Of Floor (Carpet/Hardwood, Laminate, Vinyl, Tiles, etc.)
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