OTR Install Request Form ($120) Customer Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone 1Phone 2Phone 3Pick Up New Unit At: Van Vreede's DC Green Bay Store Oshkosh Store Customer Home Install date preference: ASAP Preferred Date Preferred Date* MM slash DD slash YYYY Date OTR will be available at location:* MM slash DD slash YYYY Order Number Salesperson Name (Not Number)* Email address to send verification to:* Notes Visit Us 2610 W. Wisconsin Ave. Appleton, WI 54914 Contact us 920-733-2045 service@howievoigt.com Open Hours M-F: 7:30am - 5:00pm Howie Voigt Appliance Service Center
