Wheel Service Install Form

"*" indicates required fields

Customer Information

Location Name i.e. Business Name*

Name (Primary Contact @ Location)*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Customer Email*

Employees Trained On Wheel Service Equipment

Number of Employees Trained*

Select the number of employees trained on wheel service at this location.

Employee Name #1*

Employee Name #2*

Employee Name #1*

Employee Name #2*

Employee Name #3*

Employee Name #1*

Employee Name #2*

Employee Name #3*

Employee Name #4*

Employee Name #1*

Employee Name #2*

Employee Name #3*

Employee Name #4*

Employee Name #5*

Employee Name #1*

Employee Name #2*

Employee Name #3*

Employee Name #4*

Employee Name #5*

Employee Name #6*

Employee Name #7*

Employee Name #8*

Installer Information

Company Name:*

Date of Installation

MM slash DD slash YYYY

Installer Account #*

Installer Invoice #*

Wheel Service Equipment Installed

Tire Changers

R140i

R145/R145DR w / Plus83

R146R

R247D Centerlock

R501

R511/R541/R573

R560

R1150 Leverless

R1200 Leverless Pro

R1250 Leverless Pro

PLUS91SA

PLUS91N

Balancers

R148/R138

R155

R180

R544/R540

Alignment Systems

R1065

R1070

R1080 Plus

R1085

R1090

R5000HD

Other

Item 1

Item 2

Item 3

Item 4

Product Serial Number(s)

Serial numbers will begin to display when selections are made from above. If you have multiple products with the same item number, just enter them in the same line separated by a comma.

R1200 Leverless Pro Serial #*

R1150 Leverless Serial #*

R247D Serial #*

R145/R145D w / Plus83 Serial #*

R146R Serial #*

R140i Serial #*

R501 Serial #*

R560 Serial #*

R511/R541/R573 Serial #*

PLUS91SA Serial #*

PLUS91N Serial #*

R180 Serial #*

Did machine pass calibration check out of the box?*

Yes

No

R155 Serial #*

Did machine pass calibration check out of the box?*

Yes

No

R148/R138 Serial #*

Did machine pass calibration check out of the box?*

Yes

No

R544 / R540 Serial #*

Did machine pass calibration check out of the box?*

Yes

No

R1090 Serial #*

R1080 Plus Serial #*

R1070 Serial #*

R1065 Serial #*

R5000HD Serial #*

Item 1 Serial #*

Item 2 Serial #*

Item 3 Serial #*

Item 4 Serial #*

Submit Mileage

IMPORTANT NOTE - Wheel Service installs pay AFTER the first 100 miles. Please enter the "amount to bill" mileage in this field.

Mileage Number (Billable Miles)

Product Photography

File 1

Max. file size: 256 MB.

File 2

Max. file size: 256 MB.

File 3

Max. file size: 256 MB.

File 4

Max. file size: 256 MB.

Utilities

If you are preparing this form and would like a copy for your records, please include your email address below.

Form Preparers Email