Countryside Services - Service Request Form

Request a residential service call
(if this is an emergency please call us directly at 763-479-1600 24 hours a day 7 days a week 365 days a year)

Full Name:
Email:
Phone:	is this a Cell Phone or a Home Phone
Street Address:
City, State, Zip:
Equipment:	Furnace AC Other:
Describe reason for service:
	A service coordinator will contact you to schedule and confirm a visit. If this is an emergency please call 763-479-1600 for 24 hour service.
Other:	How did you hear about Countryside Heating & Cooling? Newspaper Ad or Flyer Magazine Ad Direct Mail Card TV or Cable Commercial Referral (if so, who referred you?: ) Internet Search or Web Link (if so, from what website?: ) Other:

	Thank you for choosing Countryside Heating & Cooling!