Form Sample 2021 TELL US ABOUT YOURSELFFirst Name*Last Name*Phone*Email* Business Name*Business Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about us?Select belowAdvertisementSocial MediaReferralEmail MarketingVehicle AdvertisingInternet SearchOtherWould you like to subscribe to Gina Marie email updates?FREE Assessments & Consultation for subscribers. Save on your next refrigeration maintenance!Select belowYesNoSERVICE TYPE What type of establishment do you operate?Select belowSupermarketConvenience StoreRestaurantSpecialty ShoppeCorporate CafeteriaFood ProcessingWarehousingLife Science - Pharmaceutical or MorgueAeronautics, Telecommunications, Cloud StorageOtherIs this your first experience with Gina Marie?Select belowYesNo (Received service within the last year)No (Received service over a year ago)ENTER PROJECT DETAILS How can Gina Marie Refrigerator Door medics assist you? Describe your issue below. What are you having issues with? Select all that apply. Doors not closing Freezing & icing shut Door off hinges Condensation issues Shattered glass door Lights are flickering or out Damage & hazardous metal (door entry or floor) Temperature not holding Powerslider not operating Cold room panels leaking Need cold room built Need door(s) relocated Cooler or Freezer*Select belowPrep RoomClean RoomProcess RoomHow many doors need repair for photo taken?*Select below12345OtherApproximate Refrigerator Door Size*Select below2’ x 2’2’ x 3’2’ x 5’2’ x 6’30” x 63”30” x 73”30” x 84”36” x 84”48” x 84”60” x 84”72” x 96”84” x 96”96” x 120”120” x 144”144” x 14’OtherWhat style of refrigerator or freezer door?*Select belowGlass Hinge DoorSolid Panel Stainless DoorCold Room Walk-in Swing DoorCold Room Sliding DoorSliding Glass DoorLift Up Showcase Glass DoorAir Curtain DoorRefrigerator or Freezer door?*Select belowGlass Reach-In DoorWalk-In Door HingedLow Boy - Bain Marie DoorUpright DoorWalk-In SliderSliding Glass Showcase DoorPower Slider DoorImage Upload Drop files here or Select files Accepted file types: jpg, png, jpeg, Max. file size: 10 MB, Max. files: 3. Upload up to 3 images of your project or issue you are experiencing. File size cannot exceed 10MB and must be .jpg, .png, or .jpeg format.CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
