MR TRUSTY WHEELZ INC Service Agreement Form

MR TRUSTY WHEELZ INC — Towing & Roadside Assistance Agreement

2785 E. Grand Blvd, Detroit MI 48211 | 866-788-9111 | support@trustywheelz.com | www.trustywheelz.com
Customer Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Color
License Plate Number
Vehicle VIN
Service Location Address (where vehicle is located)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Type of Service Needed
Destination Address for Tow (if applicable)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Payment Method
Release of Liability: I acknowledge and agree that MR TRUSTY WHEELZ INC and its representatives are not responsible for any damage to my vehicle or its contents during the provision of towing or roadside assistance services.
Agreement to Pay: I agree to pay all fees and charges associated with the services provided by MR TRUSTY WHEELZ INC.
Customer Signature
Date

MonthDayYear
Date
Should be Empty:

MR TRUSTY WHEELZ INC — Towing & Roadside Assistance Agreement