Mobile Service Request Form

Mobile Service Request Form

For Mobile Service Requests please fill out as thoroughly as possible. Pricing will be based on when a tech was contacted, not when they arrive on scene unless otherwise stated. Mobile service is on a first-call first-serve basis.
Sign below confirming you understand our Mobile Service Rate is $125/hour with a 2 hour minimum-- $100 call out fee --$2 per mile for calls over 10 miles * Call out fee is collected up front and is separate than the repair bill and non-refundable.*

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Contact Information:

Person to make decisions on repair.
Company Name*
Contact Person/ Account Authorizer*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Driver Name (if different from above)

First NameLast Name
Driver Phone Number
Please enter a valid phone number.
Service Details:

Information about equipment needing service.
Address of mobile service*
Are you in a safe location: You are located where you have access to temperature controlled environment, food, water, and/or on the side of the road and not blocking traffic.*

YesNo
Type of equipment*
Equipment Info*
Make, Model, Year
FULL VIN number*
Unit number (if applicable)
Mileage/hours*
License plate #/ state registered*
What services are you needing? What is wrong with the equipment? The more detailed the better.*
Upload picture(s) of issue if necessary:

Cancelof
Need a tow? If yes, please close this form and contact your closest tow company for arranging tow.
If the service exceeds $1,000, In A Pinch Diesel Services will reach out to authorizer of account to obtain approval of further service. If the authorized amount is lower than $1,000 please type amount below.*
Enter your budget. (i.e. $500)
Accounts Payable

Who will be making the payment decisions.
Purchase order/reference number (if applicable)
Accounts payable contact*

First NameLast Name
Accounts payable email*
example@example.com
Accounts payable phone number*
Please enter a valid phone number.
Sign below confirming you understand a 3.25% convenience fee will be added to all payments made by credit or debit card. This fee will be due at the time of credit or debit card payment and is non-refundable. *

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Sign below that you agree that the technician may have to leave the location to source parts or grab other equipment and time spent will be billed unless otherwise stated. *

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Payment form for mobile service*
This is separate from the call-out fee below.

Call-out fee*

Call-out Fee

This fee helps keep hassle and worry out of both parties. Once this fee is collected our technician will be dispatched to your location.

$100

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Mobile Service Request Form

Contact Information:

Service Details:

Accounts Payable