Breathe Legal Machine Repair Form

Date Submitted * +

Franchisee Group Name *

Name of Person Submitting Repair Request *

Franchisee Mailing Address * 🛈

City *

State *

Zip Code *

Email Address *

Franchisee Contact Phone Number *

Machine Serial Number *

Is Machine Currently in Operation at an Establishment? If yes, list Establishment Name. *

Yes Yes

Description of Machine Issue * 🛈

Provide Eport Serial Number if this is an Eport issue

Key/Lock # *

Please answer to the best of your knowledge *

Need Replacement Part Ordered

Machine needs to be sent to corporate

Both

Attach Image of Issue if Available

Notes