Emergency Road Service Call Form
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Service Tech Phone Number
Format: (000) 000-0000.
Dealer Performing Service
Eastern Iowa Tire
Heartland Tire-Omaha
OK Tire
Alma Tire Companies
Southside and Garrett Tire
Wentworth Tire
Heartland Tire-Kansas City
Holyoke Tire and Auto Service
Please Choose
Roll Time to Eagle Teleservice
YES
Caller Name
First Name
Last Name
Customer Company Name
Call Time
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Day
Year
Date Picker Icon
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Minutes
AM
PM
AM/PM Option
Caller or Primary Company Email
example@example.com
2nd E-mail
Not Required
Call Back Number
-
Area Code
Phone Number
Service Tech Name
First Name
Last Name
Driver Phone Number
-
Area Code
Phone Number
Type of Unit
Trailer
Tractor
Box Truck
Other
Unit Number
Unit Mileage
*
Wheel Position
*
LF
RF
LFO
RFO
LFI
RFI
LRO
RRO
LRI
RRI
LMI
LMO
RMI
RMO
Rim/Wheel Damaged
YES
NO
Tire Size
295/75R22.5
275/80R22.5
11R22.5
445/50R22.5
455/55R22.5
315/80R22.5
285/75R24.5
275/80R24.5
11R24.5
10.00-20
255/70R22.5
Other
Replacement Tire
Disposition Of Off Tire
*
Returned to Dealership and Scrapped
Returned with Customer
Returned to Dealership and Held For Customer
Casing Exchange
Run Flat
Brake Skid Flat
Un-Repairable
Repair Only
Off Tire Remaining 32nds
*
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Tire Replacement Reason
*
Run Under-Inflated
Crown Cuts
Sidewall Cuts
Impact Break
Worn out
Repair Only
Remove and Install QTY
Dismount and Mount - Vehicle QTY
Aluminum valve Stem QTY
Brass Valve Stem QTY
Flow Through Valve Cap QTY
Reconditioned Rim QTY
Additional Service Items
Roll Time
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Hour
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Minutes
AM
PM
AM/PM Option
Drivers Signature
Drivers Name
First Name
Last Name
Comments
Photo Of Unit Number
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Photo Of License Plate
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Photo of Off Tire/s Before Work
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Photo of Tire/s After Work is Complete
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