East Coast Diesel-Durham
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
Puerto Rico
Saint Lucia
State:
*
Postal Code:
*
Address Name:
*
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New Unit Questionnaire
What type of chassis is this unit:
*
Select Unit Type
Canteen Vending
Cash Customer Only (default)
CONSTRUCTION EQUIPMENT
Contract Rates
Contract Services, No System Or Component
Donlen (Suburban Propane)
Duplicate of Fleet-Medium Duty Vehicle
East Coast Diesel Units
ECD/CPR
Fleet Light Duty Vehicle
Fleet-Bus/RV
Fleet-Medium Duty Vehicle
Fleet-Tractor
Fleet-Trailer
Garda Unit's
HILLDRUP
HILLDRUP TRAILER
INTERNAL USE
Lewis Tree Service
Light Duty
MIMS TRACTOR
MIMS TRAILER
Misc
Moving company
Parrish medium duty
PICKUP TRUCK
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
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:
*
Address Name:
*
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
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:
*
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
Cheque
Comchek
Credit Card
Customer Credit issued
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