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 scheduling needs/requests or more information you’d like to provide? 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" E&M Home Service will try to accommodate special circumstances and special scheduling needs when possible. **By clicking the checkbox, you understand that this Service Request DOES NOT guarantee you the service date selected. We will call you or reply via email to confirm your appointment. Please add email@example.com to your email contacts so our response does not go to your spam folder.** (Required) I understand. ALL RIGHTS RESERVED.