Work Verification Form

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WORK VERIFICATION FORM
Clear Vision Facilites Management
877-912-5327  FAX 805-214-7346
1525 Rancho Conejo Blvd., #207
Newbury Park, CA 91320
JOB NAME/SITE NUMBER
CONTACT NAME
DATE OF CALL
JOB ADDRESS
JOB PHONE
CITY & STATE/ZIP
CUSTOMER W.O. / PO #
SERVICE TYPE
GLASS REPLACMENT
LOCKS
qRegular Hours
qAnnealed qLami qTemp q IG Unit
qKey Cylinder
qThumb Turn
qE/S Calll
qSpecify color _________________
qHook or Straight throw
qOther
qAfter Hours
qSize ________________________
qPaddle device
qBoard Up
qPanic Hardware (specify type)
Thickness:
q3/16" q1/4"
q1/2" qOther
Size __________
DOOR REPAIRS
qACTIVE LEAF qINACTIVE LEAF
**SPECIFY ENTRANCE LOCATION ______________
Door Type
Closers
Pivots
Hinges
qOffset
qButt
qAluminum
qSurface Mount
qCOC
qCenter Hung
qSpring Loaded
qSteel
qSpeciality Closer (Specify Type) __________ qTop
qContinuous
qWood
qCloser Arm ( Specify Type) ______________
qBottom
qOther
qOther
SERVICES PERFORMED:
This is to certify that the above repairs and/or replacements have been made as specified above and that the work
has been completed in a satisfactory manner. If the work is not covered by insurance, or if an insurance carrier
disputes and/or denies claim, then the undersigened will be responsible for payment in full.
Print Name
Signature
Date
Store Stamp

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