Customer Machine Repair Form

Company Name*
Company Address*
Street Address City State ZIP Code
Contact Name Regarding Repair Questions*
First Last
Contact Phone Number*
Contact Email*
Machine Make & Model*
Glue Part Number*
Upload SDS - We must have the SDS to begin working on your machine.
Max. file size: 50 MB.
Are you sending your machine to CGM?*
- Yes
- No - I want a technician to visit my facility to look at the machine/equipment.
We will contact you within one business day to collect the information needed to get you a quote. Please add any other information we need to know below.
Why are you sending the machine in for an evaluation?*
- It isn't heating up.
- It isn't pumping.
- It isn't powering on.
- There is an error sign/giving fault.
- Other
Date you will send your machine in for assessment*
Month
Day
Year
Requested date for the return of the machine*
Month
Day
Year
Has anyone else serviced this equipment? If yes, what was done and when was it serviced?*
If this is a repair, would you like the equipment cleaned as well, or only complete the repair?*
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