SERVICE REQUEST FORM
SOUTHLAND APPLIANCE CORP.
3905 Indian River Rd. Cheasapeake VA 23325
(757)420-1020
Where
Service
Still Matters !
email :
home phone:
work phone:
cell phone:
how would you prefer we contact you:
first name:
last name :
address :
city :
state :
zip :
brand :
product :
model :
serial :
(optional) problem :
requested service date :
additional comments: