External Field Service Form

Benco Account #:

Check here if you are a Strategic Markets customer

Service Type Request (Choose One): *
Field Service Technician VisitTune Up Program Set-up or Prescheduled Maintenance ProgramEquipment Part RequestSend out Small Equipment and Handpieces for Repair or request Reupholstery

Contact Name: (Multiple names can be entered if applicable, separated with a comma)*

Email Address: *
Additional email addresses can be entered separated with a comma

Office Name: *

Office Phone Number: *

Office Address: (Please enter full address) *

Contact Phone Number (if different from office):

Office Hours (Monday - Friday) *

Completing on behalf of the customer?
Yes

Benco associate requesting name:*

Benco associate email:*

Benco associate phone number:*

Preferred Day or Next Available *
Next AvailableChoose Date

Choose Date: *

PO Number (if required)

How many operatories are at the location? *

Is this request confidential? (meaning it should not be discussed with the customer associates) *
YesNo

Should the completed report be sent to *
CustomerBenco AssociateBoth Benco Associate & Customer

Part Number(s): *
(If part number unknown, please include photo(s) of part required.)

Quantity *

If Ordering Upholstery/Style & Color:

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Equipment Type Information (Example: Compressor, Vacuum, Sterilizer, Handpiece and Ultrasonic cleaner, etc.) *

Manufacturer Name, Make, Model Information: *

Serial Number (if applicable): *

File Upload:

Detailed Description of Issue/s (All tasks needing attention, operatory number/s, nature of problem, etc.) *

Detailed Description of Issue/s (All tasks needing attention, operatory number/s, nature of problem, etc.)

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