Diesel Work Request
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Email *
License Plate Number *
Check one *
CUSTOMER: First Name *
CUSTOMER: Last Name *
CUSTOMER: Phone and/or extension number *
CUSTOMER: Street, Town, Zip
CUSTOMER:  Please indicate the Year / Make and Model of your vehicle (i.e. 2018 Ford F250 Pickup)   NOTE:  Vehicles 10 years or over are not accepted (unless they provide an educational value to the students. ) *
PREPAID SERVICES
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CUSTOMER:  Indicate the work you are requesting to be performed on yor vechicle.
CUSTOMER: If "OTHER", describe work to be done and/or problem with vehicle.
CUSTOMER:  I understand payment is due in full to picking up job requested.*** Scholarship Fee: In lieu of labor charges a scholarship fee will be applied to the total bill.The scholarship fund  assists students with continuing education, tools and supplies. A $5 fee will be applied on orders at $50 and under. Jobs over $50 will be charged 10% of total charges.  Enter your name below to indicate you have read and understand the payment policy. *
CUSTOMER: I make this disclosure pursuant to G.L.c.268 A,?23 (b)(3) in order to dispel any appearance of potential conflict of interest, that I may beimproperly or unduly influenced in the performance of my official duties, or that I would be likely to act or fail to act as a result ofkinship, rank, position or the undue influence of any part or person.I publicly Disclose the Following Facts (Please be Specific): *
A copy of your responses will be emailed to the address you provided.
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