ECD-DBA Coast to Coast Fleet Services & Truck Repair
New Customer Questionnaire
Company Name:
*
First Name:
*
Last Name:
Phone:
*
Email:
*
Billing
Billing Address:
*
Select Address
Add an Address
Street Address:
*
Street Address 2:
City:
*
Country:
*
United States
Canada
Australia
China
Dominican Republic
Germany
Greece
Hong Kong
Mexico
New Zealand
Puerto Rico
Saint Lucia
Saudi Arabia
State:
*
Postal Code:
*
Address Name:
*
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New Unit Questionnaire
What type of chassis is this unit:
*
Select Unit Type
ARAMARK
ARAMARK-MEDIUM DUTY GAS
Canteen Vending
Cash Customer Only
CONSTRUCTION EQUIPMENT
Contract Rates
Contract Services, No System Or Component
DO NOT USE
DO NOT USE
Donlen (Suburban Propane)
Duke Energy Fleet-Light Duty GAS
East Coast Diesel Units
ECD/CPR
FLEET - LIGHT DUTY DIESEL
Fleet-Bus/RV
Fleet-Equipment
FLEET-FORK LIFT/YARD TRUCK
FLEET-LIGHT DUTY DIESEL
Fleet-Light Duty GAS
Fleet-Medium Duty Vehicle
Fleet-Tractor (default)
Fleet-Trailer
Garda Unit's
HILLDRUP TRAILER
INTERNAL USE
Lewis Tree Service
Lien needs to filed
Light Duty
Marine Diesel
MIMS TRACTOR
MIMS TRAILER
Misc
Moving company
Parrish medium duty
PICKUP TRUCK
Utility Trailer-Non DOT.
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
Street Address:
*
Street Address 2:
City:
*
Country:
*
United States
Canada
Australia
China
Dominican Republic
Germany
Greece
Hong Kong
Mexico
New Zealand
Puerto Rico
Saint Lucia
Saudi Arabia
State:
*
Postal Code:
*
Address Name:
*
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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
Street Address:
*
Street Address 2:
City:
*
Country:
*
United States
Canada
Australia
China
Dominican Republic
Germany
Greece
Hong Kong
Mexico
New Zealand
Puerto Rico
Saint Lucia
Saudi Arabia
State:
*
Postal Code:
*
Address Name:
*
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
Comchek
CTC JACKSON CREDIT CARD
CTC JACKSONVILLE AMEX
Debit Card
Discover
E-Check
EFS
EFT
Fleet One
MasterCard
Payroll Deduction
SquareUp
T-Check
Visa
ZELLE
How did you hear about us (e.g. shop website):
Submit
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