bainonline-request-ac

AIR CONDITIONING SERVICE REQUEST FORM

**For non-emergency service requests only**

If you have no air conditioning, please call 336-299-0531 (Greensboro),
336-887-1960 (High Point) or 336-784-6079 (Winston-Salem) for service.

Please fill out the form as completely as possible. Fields marked with an asterisk (*) are required.

Customer Type

Agreement

Account Number

Please provide at least one phone number, and an email address so we may contact you.
Please make sure your contact information is accurate.
We respect your privacy. We will not sell or distribute your contact information.

Full Name*

Email*

Phone Number*

2nd Phone Number

Address

City

State

Zip Code

Description*