Equipment Repair Request
Name
*
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Company Name
*
Equipment Information:
Unit Number/License Plate
*
Equipment Make:
Please Select
Peterbilt
Freightliner
Kenworth
International
Volvo
Mack
Western Star
Caterpillar
Komatsu
Hitachi
John Deere
Ford
Chevrolet
GMC
Dodge
Mazda
VW
Toyota
Hitachi
Hyundai
Bucyrus
Other
Equipment/Vehicle Model
*
Year:
*
VIN (Vehicle Identification Number)
*
Kilometers / Hours
*
Location/Address
*
Back
Next
Repair Details:
Type of Service Needed:
*
Regular Maintenance
Engine Repair
Transmission Repair
Electrical System
AC/Heating
Tires
Air System
Brakes
Describe the Problem (be as detailed as possible)
*
Do you require towing services?
Yes
No
Preferred Service Date:
*
-
Month
-
Day
Year
Date
Preferred Time Slot:
Hour Minutes
AM
PM
AM/PM Option
to
until
Hour Minutes
AM
PM
AM/PM Option
Upload Photos of the Damage/Issue (if any):
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Terms & Agreement:
*
*
Submit
Should be Empty: