Service Request Your Name (required) Your Email (required) Your Phone (required) Is this a cell phone? YesNo Street Address(required) Apartment YesNo City State Zip Preferred Service Date, if available: Appliances Repairs (Check as many as needed): Cook TopDishwasherDisposalDryerFreezerIce MakerOvenRangeRefrigeratorWasherOther If "Other" is selected, please specify here: Please provide manufacturer, model number & describe issues: Are there any special needs or requests? Examples might include: "Work night shift", "Call after 1pm, please", "Door bell is broken, please knock loudly", "Pull around to back driveway", "Need special hours", "Work M-F, 8-5" Appliance Repair Dallas will try to accommodate special circumstances and needs when possible. **By clicking the checkbox, you understand that this Service Request DOES NOT guarantee you the date selected. We will call you or reply via email to confirm your appointment.** (Required) I understand. ALL RIGHTS RESERVED.