Service request Authorization

SECTION A - Property Information

Property Name:
Address:
City, St, Zip:
Case #:

Contact Information of Employee Authorizing Service Request

Employee Name: Title:
Email Address: Phone:
Email the completed form to helpdesk@adcommtv.com

This document authorizes AdcommTV to dispatch a repair technician to your facility to diagnose and
repair the issues at your service location. Please review the section and verify that the details
accurately reflect the reason for your dispatch. If the fault is found to be with the AdcommTV system
and no warranty is in effect, the property accepts full financial responsibility for all labor, parts and
equipment associated with the repairs. In the event a warranty is in effect, the property acknowledges
that the distribution/cabling infrastructure, televisions, room cabling, third party equipment,
negligence, physical abuse, acts of nature, or other equipment that is not part of the AdcommTV
system, are not covered under warranty and the property accepts full financial responsibility for all
labor, parts and equipment associated with the repairs.

Should you have any questions or concerns regarding the financial obligations of the Service request
Authorization please contact our Technical Support Group at 866-272-7982 for clarification prior to
signing and returning this form. Failure to cancel your service request will result in a standard dispatch
fee of $299.00 being charged. By signing this form you acknowledge that you are authorized on behalf
of your property to approve a technician dispatch and any and all parts and labor charges that may be
associated with the dispatch.

SECTION B - Service Request Authorization Details

Reason for Dispatch:

AUTHORIZED SIGNATURE _________________________________________ DATE___________________