Representative Work Order Request

Order Form Date

YYYY

Work Completion Date

YYYY

Site Name

Model

Electronic or Basic Model Kiosk

Name of Representative Submitting

First Name

Last Name

Serial Number

Label

Is there a label inside the back panel?

Address of Kiosk Location

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number of Kiosk Location

Kiosk Contact

Who is the best person to contact in regards to this kiosk?

First Name

Last Name

Hours to Contact

What are the best hours to reach the contact person?

Orange Labels

Does the kiosk have an orange label on the front?

Roll Bucket

Does the kiosk have a roll bucket?

Kiosk Inspection: Body

Is the body of the kiosk in good condition or does it need repair?

Kiosk Inspection: Paint

Does the paint look good or does it need recoating?

Kiosk Inspection: Bucket Door

Test the bucket door. Does it close all the way or does it need repair?

Kiosk Inspection: Integrity of Pin

Is the pin good or does it need replacement?

Kiosk Inspection: Electronic Board

Does the electronic board look good or need replacement?

Kiosk Inspection: Locks

Do the locks look good, need repair, or replacement?

Recommendation

Comments

Any additional information or concerns with the operation of the kiosk.