Fields marked with an (*) are required fields.
 
Contact Information
* Company:   
* Street:   
* City:   
* State or Province:   
* Zip Code:   
* Country:   
* Contact Name:   
* Phone:   
* Fax:   
* Email:     
                           
 
Product Information
Make: 
Model: 
* Serial Number:   
Hour Meter Reading: 
 
Product Owner Information
Same as contact information
* Current Company:   
* Current Owner:   
* Current Owner Street:   
* Current Owner City:   
* Current Owner State or Province:   
* Current Owner Zip Code:   
* Current Owner Country:   
* Current Owner Telephone:   
* Current Owner Fax:   
* Current Owner Email:    
                          
* (For current owner information, please do not include entities renting or leasing units)
 
Type of Evaluation Request (check applicable box)
Product Modification or Special Application:  (No fee)
Machine Damage - Consult Factory, Non-Incident
or Incident Related Damage: 		  (No fee)
On-Site Evaluation by Product Safety & Reliability Representative:  ($600.00 Fee, Plus Expenses)
*  Description of Request:   
* Are there any injuries or property damage?  


** ALL REQUEST MUST INCLUDE PHOTOGRAPHS, ILLUSTRATIONS, OR SKETCHES.
THESE MAY BE ATTACHED ON THIS FORM, EMAILED TO: PRODUCTSAFETY@JLG.COM,
OR MAILED TO:
ATTN: PRODUCT SAFETY, 13224 FOUNTAINHEAD PLAZA, HAGERSTOWN, MD 21742