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Repair & Equipment Replacement Form
Customer Contact Information
Name
*
Phone
*
Email
*
Business Name
*
Job Title
*
Request Type (Choose one):
*
Repair
Equipment Replacement
Item 1
Product Type to Repair or Replace
ANSI Pump
Dry Screw Pump
Rotary Vane Pump
Rotary Piston Pump
Liquid Ring Pump
Vacuum Booster
Positive Displacement Blower
Self-Priming Trash Pump
Close Coupled Centrifugal Pump
Other
Manufacturer Name of Product
Goulds Pumps
Tuthill
Kinney
M-D Pneumatics
Atlantic Fluidics
Stokes
Edwards
Leybold
Welch
DuroFlow
Rietschle
Roots
Aerzen
Sutorbilt
Gardner Denver
Busch
Spencer
Alcatel
Kice
Titan Pump
Gorman Rupp
Aurora
Other
Product Model Number
Product Serial Number
Qty of Units
1
2
3
4
5
Oil Type Currently Used
Please list Product Type if Other is selected (Item 1):
Please list Manufacturer if Other is selected (Item 1):
Item 2
Product Type to Repair or Replace
Rotary Vane Pump
Dry Screw Pump
Rotary Piston Pump
Liquid Ring Pump
Vacuum Booster
Positive Displacement Blower
ANSI Pump
Self-Priming Trash Pump
Close Coupled Centrifugal Pump
Other
Manufacturer Name of Product
Tuthill
Kinney
M-D Pneumatics
Atlantic Fluidics
Stokes
Edwards
Leybold
Welch
DuroFlow
Rietschle
Roots
Aerzen
Sutorbilt
Gardner Denver
Busch
Spencer
Alcatel
Kice
Titan Pump
Goulds Pumps
Gorman Rupp
Aurora
Other
Product Model Number
Product Serial Number
Qty of Units
1
2
3
4
5
Oil Type Currently Used
Please list Product Type if Other is selected (Item 2):
Please list Manufacturer if Other is selected (Item 2):
Item 3
Product Type to Repair or Replace
Vacuum Booster
Dry Screw Pump
Rotary Vane Pump
Rotary Piston Pump
Liquid Ring Pump
Positive Displacement Blower
ANSI Pump
Self-Priming Trash Pump
Close Coupled Centrifugal Pump
Other
Manufacturer Name of Product
Tuthill
Kinney
M-D Pneumatics
Atlantic Fluidics
Stokes
Edwards
Leybold
Welch
DuroFlow
Rietschle
Roots
Aerzen
Sutorbilt
Gardner Denver
Busch
Spencer
Alcatel
Kice
Titan Pump
Goulds Pumps
Gorman Rupp
Aurora
Other
Product Model Number
Product Serial Number
Qty of Units
1
2
3
4
5
Oil Type Currently Used
Please list Product Type if Other is selected (Item 3):
Please list Manufacturer if Other is selected (Item 3):
Item 4
Product Type to Repair or Replace
Positive Displacement Blower
Dry Screw Pump
Rotary Vane Pump
Rotary Piston Pump
Liquid Ring Pump
Vacuum Booster
ANSI Pump
Self-Priming Trash Pump
Close Coupled Centrifugal Pump
Other
Manufacturer Name of Product
Roots
Tuthill
Kinney
M-D Pneumatics
Atlantic Fluidics
Stokes
Edwards
Leybold
Welch
DuroFlow
Rietschle
Aerzen
Sutorbilt
Gardner Denver
Busch
Spencer
Alcatel
Kice
Titan Pump
Goulds Pumps
Gorman Rupp
Aurora
Other
Product Model Number
Product Serial Number
Qty of Units
1
2
3
4
5
Oil Type Currently Used
Please list Product Type if Other is selected (Item 4):
Please list Manufacturer if Other is selected (Item 4):
If the current unit has failed, what was the nature of the failure?
Additional Remarks:
Human Verification
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