East Coast Diesel-Durham
New Customer Questionnaire
Company Name:
*
First Name:
*
Last Name:
Phone:
*
Email:
*
New Unit Questionnaire
What type of chassis is this unit:
*
Select Unit Type
Bus/RV
Canteen Vending
CONSTRUCTION EQUIPMENT
Contract Rates
Contract Services, No System Or Component
DO NOT USE THIS UNIT TYPE
Donlen (Suburban Propane)
East Coast Diesel Units
ECD/CPR
Fleet Light Duty Vehicle
Fleet-Tractor (default)
Garda Unit's
HILLDRUP
HILLDRUP TRAILER
INTERNAL USE
Lewis Tree Service
Light Duty
Medium Duty Vehicle
MIMS TRACTOR
MIMS TRAILER
Misc
Moving company
Parrish medium duty
PICKUP TRUCK
Trailer
Utility Trailer-Non DOT.
Yard Vehicle or Lift Truck
VIN
:
Year:
Make:
Model:
Unit Number:
Unit Nickname:
License Plate:
Service Request Questionnaire
Complaints / Problems / Requests
Describe first complaint, problem, or request:
*
How urgent is this:
*
Schedule as soon as possible
Schedule repair today
Emergency -Please perform Service Today
Schedule for this weekend
Add another
Scheduling & Authorization
When will the unit be available for repairs:
Now
The unit MUST be accessed at the above date and time.
When would you like the unit back:
Return ASAP
How would you like us to access the unit:
*
Select Access Method
No preference, just get it done!
Customer will bring unit to the shop
Shop will service unit on-site
Shop will pick up unit and bring to the shop
Shop will tow unit
Where will this unit be located for access:
*
Select Address
Temporary Address (please put address in the Helpful Notes below)
Add A New Address
Address Name:
*
Street Address:
*
Street Address 2:
City:
*
Country:
*
United States
Canada
Australia
China
Dominican Republic
Germany
Greece
Hong Kong
Mexico
Puerto Rico
Saint Lucia
State:
*
Postal Code:
*
Save
Cancel
Would you like the shop to deliver the unit:
*
No - Customer will pick up unit from shop
Yes - Shop will return unit to customer
Where would you like this unit delivered:
*
Select Address
Temporary Address (please put address in the Helpful Notes below)
Add A New Address
Address Name:
*
Street Address:
*
Street Address 2:
City:
*
Country:
*
United States
Canada
Australia
China
Dominican Republic
Germany
Greece
Hong Kong
Mexico
Puerto Rico
Saint Lucia
State:
*
Postal Code:
*
Save
Cancel
Authorization Number:
PO Number:
Notes and Instructions For Shop:
Step 4: Additional Information:
Unit Identifier:
Driver Name / #:
Engine:
Reference #:
Payment Method:
Select Payment Method
ACH
American Express
Cash
CASH APP
Check
Cheque
Comchek
Credit
Credit Card
Debit Card
Discover
E-Check
EFS
EFT
Fleet One
Gift Card
Internal Payment
MasterCard
National Account Credit
PayPal
Payroll Deduction
T-Check
Third Party
Visa
ZELLE
How did you hear about us (e.g. shop website):
Submit