Customer & In Field Registration

ADVANCED DIAGNOSTICS

Contact-us@servicemytrucks.com
www.servicemytrucks.com

(678) 744-9935
Customer Details:
Company Name*
Owner's Full Name (Person/Entity Responsible for payment)*

First NameLast Name
Contact person if different from above

First NameLast Name
Owner's Cell Number*
(Person/Entity Responsible for payment)
Contact Person's Cell Number
E-mail*
(Person/Entity Responsible for payment)
Alternate E-mail
example@example.com
Is it okay to receive text messages from Advanced Diagnostics at either phone numbers?*

YesNoOnly PrimaryOnly Alternate
Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Which payment method will you be using today (more than 1 can be selected)*

ZelleCashCredit/Debit (Visa, MC, Disc) (3% fee)
* If your paying with Zelle please provide your Zelle so we may send a payment request to you Zelle phone# OR email.
Additional fee may apply*

I understand an additional 3% fee will be added to the total invoice amount for options marked as 3%
Credit card on file required*

A Credit/Debit card is REQUIRED to be held on file for ALL PAYMENT OPTIONS
VEHICLE Details:
FULL VIN# FULL VIN#

OR

FULL TAG# TAG# State
Year*
Make / Model*
Vehicle miles (Estimate or Exact)*
D.O.T. Number*
TRUCK Number of Vehicle being Serviced*
Address where the Vehicle will receive service*

Street Address

Street Address Line 2

CityState

Zip Code
Briefly describe the issue you are having with your vehicle
Date

MonthDayYear
Date
Hour Minutes
Signature*

Clear
Authorizer responsible for payment
How did you hear about us?
Please Specify
How did you hear about us
Should be Empty:

Customer Details:

VEHICLE Details: