Company: {Company:1}

Contact: {Contact:2}

Address: {Address (Street Address):3.1}
{Address (Address Line 2):3.2}
{Address (City):3.3}
{Address (State / Province):3.4}
{Address (ZIP / Postal Code):3.5}
{Address (Country):3.6}

Email: {Email:4}

Phone: {Phone:5}

Model : {Model #:6}

Serial: {Serial #:7}

Work Required: {Work Required:8}

Submitted for: {Submitted for:9}