*Required field

Product Information:

Model:*

<Select Model> M27 Chelsea Gas Fireplace FV46 FullView Gas Fireplace FV41 FullView Gas Fireplace FV41 MOD FullView Modern Gas Fireplace M50 Greenbriar Gas Fireplace DXV60 Mendota Gas Fireplace DXV45 Mendota Gas Fireplace DXV45 Mendota Gas Fireplace (Deep Timber 3) DXV42 Mendota Gas Fireplace DXV35 Mendota Gas Fireplace (TimberFire) DXV35 Mendota Gas Fireplace (Deep Timber II) DXV35 Mendota Gas Fireplace (Deep Timber 3) X62 FlexFire Gas Fireplace Insert FV44i FullView Gas Fireplace Insert FV44i MOD FullView Modern Gas Fireplace Insert E-FV44i FullView Echo Series Gas Fireplace Insert FV33i FullView Gas Fireplace Insert FV33i MOD FullView Modern Gas Fireplace Insert E-FV33i FullView Echo Series Gas Fireplace Insert D-40 Mendota Gas Fireplace Insert D-30 Mendota Gas Fireplace Insert SDV-40 Mendota Medallion Free-Standing Gas Stove SDV-30 Mendota Medallion Free-Standing Gas Stove My model is not listed above

Serial Number:*

   (example: "WH96752")

Gas Supply:*

Natural Gas
LP (Propane)

Homeowner Information:

First Name:*

Last Name:*

Address Line 1:*

Address Line 2:

City:*

State (if USA):*

<Select State> Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

ZIP/Postal Code:*

Phone:

   (xxx xxx-xxxx)

Fax:

   (xxx xxx-xxxx)

E-Mail Address:

May we occasionally
contact you via
e-mail about Mendota
news and products?

YESNO

Dealer Information:

Dealer Name:*

Dealer City:*

Dealer State:*

<Select State> Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Dealer ZIP/Postal Code:

Date Installed:*

  (mm/dd/yyyy)   

Dealer Installation Checklist:

The following information is determined by your Authorized Mendota Dealer
at the time of installation. Your dealer has recorded this information on a
page near the back of your owner's manual. Please contact your dealer
if this information was not provided to you at the time of installation.

  Approved vent pipes and vent cap installed, per owner's manual.

  Check for proper clearances to combustibles, per pipe manufacturer's
        specifications.

  Install proper size gas lines and check for gas leaks, per owner's manual.

  Check for correct gas pressure at manifold, per owner's manual.

  Take combustion system millivolt readings, per owner's manual.

  Cycle burners ON/OFF verifying prompt ignition, per owner's manual.
          (see "Lighting Instructions")

  Install logs and adjust flame, per owner's manual.

  Brief owner on operation and maintenance of unit. (Lighting pilot,
          operating burner, and blower "delay" operation)