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LOLER Request Form

Name :

How you wish to be addressed when we contact you.

Company :

Name of company if applicable.

Phone/Contact Number:

Telephone number including area code i.e (01279) 123-456 or +441279 123-456.

E-mail Address :
Machine Location:

Please give us the location of the machine so we can estimate the travel time to site. If you don't want to add the whole address a postcocde will do.


Machine Details

Machine Make / Manufacturer :
Machine Model:
Machine Serial No.:
LOLER Expiry Date
Known Issues
Validation Code