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515-526-5346

2401 Westown Pkwy,
West Des Moines, IA 50266

Shop Hours

Mon – Fri | 7:30am – 5:30pm
Sat - Sun |Closed

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Customer Forms
- Vehicle Pick Up Form
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Customer Concern(S)

Concern #1

Concern #2

Concern #3

Concern #4

1. Rate Of Occurrence:

Once
Rarely
Often
Always
Other

2. Time of Day:

AM
Midday
PM
Random
Always
Other

3. Engine Temperature:

Startup
Cold
Warm
Normal
Random
Other

4. Outside Temperature:

Cold
Warm
Hot
Random
Other

5. Driving Conditions:

Parked
Steady
Accelerating
Decelerating
MPH

6. Gas Pedal Position:

Released
Light
Medium
Fully Depressed
Other

7. Gear Selector Position:

8. Occurs After:

Idling
Driving
Being off for 1 hours/Minutes
Other

9. Road Conditions

Dry
Wet
Smooth
Rough
Uphill
Downhill
Random

10. Fuel Level:

Octane:

After Refueling ?

Yes
No

11. Recent Repairs?

12. Are you able to easily duplicate the concern?

Yes
No

13. How?

Name *

First

Last

Phone *

Email *

Customer Sign (Name) *

Call Us

515-526-5346

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2401 Westown Pkwy,
West Des Moines, IA 50266

Business Hours

Mon – Fri | 7:30am – 5:30pm
Sat - Sun |Closed

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