GRINWALD REPAIR ORDER SIGN-UP FOR UW HEALTH PARTNER

REPAIR ORDER SIGN-UP FOR

UW HEALTH PARTNER

Grinwald Ford - Quick Lane Tire & Auto

Phone 920 261 9900

Fax 920 261 8109

quicklane@grinwaldford.com

Please Fill Out as Thoroughly as Possible

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Contact Person

First NameLast Name

Phone Number

Area CodePhone Number

E-mail

Preferred Method of Contact?

PLEASE SIGN HERE

Make Of Your Vehicle

Year Of Your Vehicle

Color Of Your Vehicle

When is the vehicle available for pick-up?

MonthDayYearHourMinutesAM/PM Option

When does vehicle need to be returned?

MonthDayYearHourMinutesAM/PM Option

Please specify any maintenance you will be needing.

Select Any of The Following:

If Chosen Other.......Please Describe as Best as Possible What Needs to be Looked at.

(Examples… rattle in front end over bumps, Check engine light on,

Pulls to the right or left, noise when turning)

Description:

Please specify any Auto Detailing you will be needing.

Please remove your personal belongings prior to clean up * If your vehicle is excessively dirty there will be a surcharge. Please inquire prior to having your vehicle cleaned.

Select any of the Following

If Chosen Other.......Please Describe as Best as Possible What Needs to be Detailed.

Description:

YOU WILL BE CONTACTED FOR ALL WORK OVER $50.00