Company Name *

Contact Name *

Phone *

Email *

Is there a Pre-Approved Service Cost Limit? *

Yes
No
Not sure

If yes, enter limit amount (optional)

Would you like A.J. Stone to contact you (or the contact noted on this form) for further approval? *

Is the best contact person listed in Section 1? *

Please provide your contact details below *

I agree to the below Terms and Conditions *

To ensure the health and safety of our employees and maintain the quality of our facility, all equipment must be fully decontaminated before it is shipped or dropped off at our facility. This policy is essential to prevent employee exposure to harmful substances that may be present on contaminated equipment and to protect the integrity of sensitive equipment during the repair process. Please be advised that our technicians reserve the right to charge a cleaning and handling fee of $250.00 if equipment arrives in a condition that requires additional cleaning. In certain cases, we may also refuse to handle or repair equipment that does not meet our decontamination standards. We appreciate your cooperation in helping us uphold our health and safety protocols and in ensuring a safe working environment for our team. By clicking this box, I understand and agree to the health and safety policy outlined above.

A.J. Stone Company Ltd. Service Department Equipment Intake Form

Job Tag Information

Your Order

"Y" with 2 Paratech Couplings and Maxiforce Nipple