Contact Information;

Name: Company: Address:

City: State: Zip: Phone:

Alt. Phone Email: Contact Preference:

Vehicle Information;

Year: Make & Model:

Service Information; (Please check all that apply)

Air Conditioning Alignment Check Battery Brakes Performance Problem

Routine Maintenance Starting/Charging Problems Steering/Suspension Problem

Pre-Owned Car Examination

Are you waiting here during service? Yes No

Do you need transportation during service? Yes No

Destination & Time:

Symptoms:

Engine light on? Misses or runs rough? Hesitates or backfires?

Engine stalls or dies? Is sluggish/on power, but not rough? Is hard to start, but cranks okay?

Engine cranks, but won't start? Stalls after starting? Fluid leaks?: Green Reddish Black Brownish Clear No

Exhaust smokes excessively?: Blue Grey Black White No

Rapidly Consumes Gas or Oil?: Gas Oil Both No Shakes or Vibrates?: Steering Wheel Seat Brake Pedal No

Other Comments;