Vehicle Service Request Form

Name:

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:

Area CodePhone Number

Email

example@example.com

Vehicle Brand

Model

Year

Serial or VIN

Electric, Gas, or Diesel

Describe the Issue:

Do you need us to pick it up?

Pick up fee is $100 Des Moines Metro or $3/mile from us to you.

Diagnostics are a flat rate invoiced when you drop your service item off or before we pick it up. This only covers our review of your product and our attempt to identify the most probable cause of the issue. We will contact you with an estimate before moving forward on your repair. All service requests could have more than one cause, and our diagnostic may prove incorrect. We cannot guarantee our initial assessment is correct, and you will be responsible for the cost of diagnostics and any services you've approved.

By submitting this request, you authorize EzipNzoom to operate your vehicle as needed to test and diagnose the issue.

We are not responsible for personal items left on or in your vehicle during service.

Payment for all service work is due prior to release of your vehicle.

Vehicles not picked up within [7] days of service completion are subject to a storage fee of $30/month, prorated at $1/day.

I understand Golf Cart and/or LSV Diagnostics is $100. This fee is due prior to any work done by EzipNzoom.

I understand Ebike and/or Scooter Diagnostics is $40. This fee is due prior to any work done by EzipNzoom.

EzipNzoom — Service Liability Waiver & Release

By signing this form, you ("Customer") agree to the following terms regarding service work performed by EzipNzoom on your electric bicycle, scooter, golf cart, or low speed vehicle ("Vehicle"):

1. Authorization. You authorize EzipNzoom to inspect, diagnose, and perform the service work you have requested or subsequently approved. The diagnostic fee you pay does not guarantee a diagnosis or completed repair — it covers the cost of inspection and estimate preparation only.

2. Release of Liability. You release EzipNzoom, its owner, employees, and agents from any and all claims, demands, liability, and causes of action — including claims arising from ordinary negligence — related to the service, inspection, repair, storage, or handling of your Vehicle while in our care. This release applies to property damage and personal injury.

3. Pre-Existing Conditions. EzipNzoom is not responsible for pre-existing damage, wear, defects, or conditions on your Vehicle that are discovered during or after service. We will note any such conditions we observe and bring them to your attention.

4. Unclaimed Vehicles. Vehicles not picked up within 30 days of notification that service is complete may be subject to storage fees. EzipNzoom is not responsible for theft, damage, or loss of any vehicle or personal property left on the premises beyond that period.

5. Payment. Payment in full is required before your Vehicle is released from our facility. We accept cash, credit/debit cards, and approved financing. Returned checks are subject to a $35 fee.

6. Limitation. This waiver does not apply to claims arising from gross negligence or intentional misconduct by EzipNzoom.

7. Governing Law. This agreement is governed by the laws of the State of Iowa.

By checking the acknowledgment box and signing below, you confirm that you have read and understood this waiver, that you are 18 years of age or older, and that you are signing voluntarily.

Check box to acknowledge the waiver

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