Schedule Your Fitness Service Employee Name If this form is being completed by a Scheller's employee, please include your name. First Name Last Name Company Name if Applicable Address City State Zip Code Contact Phone Number 1 (and name if different from above) Phone Number Type 1 Cell Office Residence Contact Phone Number 2 (and name if different from above) Phone Number Type 2 Cell Work Residence Contact Phone Number 3 (and name if different from above) Phone Number Type 3 Cell Work Residence E-mail Address Preferred Method of Contact: Phone e-mail This is equipment is located in: Private Residence (Home) Office/Work Place Health Club Rehab/Physical Therapy School/Athletic Center Community Center Other Date Equipment Purchased If you're not sure of the exact date, please approximate. Type of Equipment Make of Equipment Model Name or Number Serial Number Service Needs: Please give us as much information as you like about the nature of your service needs. I would like to receive specials via e-mail: Yes! No Thanks.