2. This form is for the use of Town of Burns Harbor employees.
4. Town of Burns Harbor employees use this form to request service or repairs to a vehicle owned by the Town of Burns Harbor.
6. Please use one form per request.
10. Contact Information
12. First Name*
13. Last Name*
15. Phone Number*
16. Email Address*
18. Department:*
20. Year, Make and Model of Vehicle that you are requesting service for:*
22. Vehicle Mileage:*
24. Service or Repair Requested*
26. Notes:

    If there is any additional information about your request that you would like the service provider to be aware of, please include in notes.

Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field