Loaner Form
Please fill this form out carefully. You may bring printed form to any of our Virginia Stores along with the vacuum that you would like us repair.

Important: We will need at least 2 forms of identification to provide you a loaner
Vacuums Unlimited
474 Elden Street
Herndon VA 20170
(In K-mart Shopping Center)
Vacuums Unlimited
14500-G Lee Rd.
Chantilly, VA 20151
Located at Rt. 50 and Lee Rd. (west of the Rt. 28, Rt. 50 interchange), opposite Costco Wholesale.
(703) 961-1740
City: State:
Zip: Home Phone:
Work Phone: Fax:
Brand of Vacuum: Model# (if known) :
Serial# (if known) :
Problem with vacuum:
How old is the vacuum?
Additional Comments:

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