Have Ambi-rad visited your site before? -- Please Select -- Yes No

Ambirad Ref. (If available)

Are you the installer? -- Please Select -- Yes No

Were units commissioned? -- Please Select -- Don't Know Yes No

By Who? -- Please Select -- Don't Know Ambi-rad Other

Has site changed names within the last 6 months? -- Please Select -- Yes No

What model of heaters do you have installed? -- Please Select -- Vision Range AR-ARE Range Herringbone Range Nor-Ray-Vac Range Vision Compact Range Optima Range ARO Range ER Range Quartz Glow Range Ceramic Plaque Range Solarglow Range UDSA Range UDSAV Range UDSBD Range UPA Range UCA Range UCB Range UCE Range SCA Range STA-2 Range STB-2 Range STE-2 Range OFSU Range UF Range UFE Range T Series Range ST Series 1 Range AC Range AC Mini Range ACR Range ACT Range Mobile Range Tornado Heater Cabinet Heater Other

Heater Type? -- Please Select -- Electric Gas Oil

Services at the heater? -- Please Select -- Electric Gas Oil

Approximate date of installation? -- Please Select -- 1979 - 1985 1986 - 1990 1991 - 1995 1996 - 2000 2001 - 2005 After 2006

How many heaters do you have installed? -- Please Select -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 > 15

Approximate height of heaters? -- Please Select -- Floor 5m < 10m < 15m < 20m < 25m < 30m < 35m < 40m > 40m

Access Equipment Required? -- Please Select -- E Own Access Equipment Tower Combi Ladder Scissor Lift

Company

Address 1

Address 2

Town/City

County

Postcode

Scope of work? -- Please Select -- Commissioning Breakdown Service

Time of available access? -- Please Select -- 00:01 --> 08:00 08:01 --> 16:00 16:01 --> 20:00 20:00 --> 00:00

Onsite parking available? -- Please Select -- Yes No

Do you require a method statement? -- Please Select -- Yes No

Customer purchase order no

Additional Information

Contact Name *

Contact Tel

I agree to adhere to the AmbiRad Terms and Conditions Yes No