Maintenance Request Form

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

Maintenance Request Form

Date of Request: {{date_of_request}}

Request Number: {{request_number}}

Requester Information

Name: {{requester_name}}

Department/Unit/Flat No.: {{department_unit_flat_no}}

Contact Number: {{contact_number}}

Email Address: {{requester_email}}

Location of Maintenance Issue

Building: {{building_name}}

Floor: {{floor_number}}

Room/Area: {{room_area}}

Specific Location Details: {{specific_location_details}}

Description of Maintenance Issue

Type of Issue (e.g., Electrical, Plumbing, HVAC, Structural, Appliance, Other): {{type_of_issue}}

Detailed Description of Problem: {{detailed_description_of_problem}}

Date Problem Noticed: {{date_problem_noticed}}

Urgency Level: {{urgency_level}} (e.g., Low, Medium, High, Emergency)

Safety Hazard Present (Yes/No): {{safety_hazard_present}}

If Yes, please describe: {{safety_hazard_description}}

Access Information

Is access to the area required after hours or on weekends? (Yes/No): {{access_after_hours_weekends}}

Is special access required (e.g., key code, security escort)? (Yes/No): {{special_access_required}}

If Yes, please provide details: {{special_access_details}}

Preferred contact method for access arrangements: {{preferred_contact_method}}

For Office Use Only

Date Received: {{date_received}}

Received By: {{received_by}}

Assigned To: {{assigned_to}}

Maintenance Action Taken: {{maintenance_action_taken}}

Date Completed: {{date_completed}}

Status: {{status}} (e.g., Pending, In Progress, Completed, Closed)

Requester's Declaration

I hereby confirm that the information provided above is accurate to the best of my knowledge.

{{requester_name}}

{{date}}

Signature Block

_________________________

Requester's Signature

_________________________

Authorised Personnel Signature (if applicable)

Name: {{authorised_personnel_name}}

Date: {{date}}