Service Intake Questions "*" indicates required fields 1Personal Information2Vehicle Information3Consent Personal InformationName* First Last Company PO# Phone #*Alternate Phone #Email* Send Estimate To Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Vehicle InformationYear* Make* Model* What are your concerns?*When did you notice the issue?*When does it happen? (Check all that apply) When starting hot When starting cold While driving While parked While idling While turning When accelerating When slowing When stopping At a certain speed While in 4x4 or 2wd Do you feel anything while driving Any noises?Any leaks?Any smells?Additional Notes ConsentConsent*I hereby authorize Supreme Diesel to an hour, diagnostic time. I acknowledge that upon inspection an estimate will be prepared and I will be contacted to receive authorization for the repair work to be done. I acknowledge that I am granting Supreme Diesel and its employees, permission to operate the described vehicle herein on streets, highways, or elsewhere for the purpose of testing and/or inspecting. I acknowledge that I will receive my vehicle only when the work order invoice is paid in full. I acknowledge that a garagekeepers lien may be placed on the described vehicle or parts here to secure the amount of repairs and the cost of thereto. I acknowledge that Supreme Diesel and its employees are not liable for any loss or damage to vehicles or articles left in vehicles in the case of theft, vandalism, fire nor any other cause beyond our control. I understand and agree*I have given signed authorization on an estimate for the work to be performed on this vehicle.* Yes No SignatureI hereby authorize Supreme Diesel to proceedHiddenTime Hours : Minutes AM PM AM/PM CAPTCHA Δ
