Get a Free Vacuum Loaner!

Please fill this form out carefully. You are required to bring the printed form to any of our Virginia Store physically along with the Vacuum to be repaired.

Important: We will need atleast 2 ID’s to provide you a loaner.

Name:	_________________________________
Address:	____________________________________________________
City:	_________________________________	State:	______________________________
Zip:	_________________________________	Home Phone:	______________________________
Work Phone:	_________________________________	Fax:	______________________________
Brand of Vacuum:	_________________________________	Model# (if known)	______________________________
Serial# (if known)	_________________________________
Problem with vacuum:
	____________________________________________________ ____________________________________________________
How long you have this vacuum with you?:
	_________________________________
Have You considered trading it with another vacuum?:
	Yes No
Your Comments:	______________________________________________________