OTR Install Request Form ($150) Customer Name* First Last 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 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
