Wheel Service Install Form "*" indicates required fields Customer InformationLocation Name i.e. Business Name*Name (Primary Contact @ Location)* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Customer Email* Employees Trained On Wheel Service EquipmentNumber of Employees Trained*123456Select the number of employees trained on wheel service at this location.Employee Name #1*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 InformationCompany Name:*Date of Installation MM slash DD slash YYYYInstaller Account #*Installer Invoice #*Wheel Service Equipment InstalledTire Changers R140i R145/R145DR w / Plus83 R146R R247D Centerlock R501 R511/R541/R573 R560 R1150 Leverless R1200 Leverless Pro PLUS91SA PLUS91NBalancers R148/R138 R155 R180 R544/R540Alignment Systems R1065 R1070 R1080 Plus R1085 R1090 R5000HDOther Item 1 Item 2 Item 3 Item 4Product 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 NoR155 Serial #*Did machine pass calibration check out of the box?* Yes NoR148/R138 Serial #*Did machine pass calibration check out of the box?* Yes NoR544 / R540 Serial #*Did machine pass calibration check out of the box?* Yes NoR1090 Serial #*R1080 Plus Serial #*R1070 Serial #*R1065 Serial #*R5000HD Serial #*Item 1 Serial #*Item 2 Serial #*Item 3 Serial #*Item 4 Serial #*Submit MileageIMPORTANT 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 PhotographyFile 1Max. file size: 512 MB.File 2Max. file size: 512 MB.File 3Max. file size: 512 MB.File 4Max. file size: 512 MB.UtilitiesIf you are preparing this form and would like a copy for your records, please include your email address below.Form Preparers Email Δ
