MANUAL ROADSIDE CUSTOMER INTAKE FORM
DISPATCHER:
Select a Dispatcher
JUSTIN
Date
Time
I want to subscribe to the Text Message SMS list.
First Name
Last Name
Service?
Diagnosis
Jumpstart
Battery Change
Jumpstart --) Potential Battery Change
Fuel Delivery
Tire Service (with Spare)
Tire Service (No Spare)
Lockout
Towing
Tire Service --) Potential Tow
Air Delivery
Winch-Out
Oil Delivery
Auto Repair
Other
Phone Number (Mobile)
Email
State
Select a State
[CANADA]
[MEXICO]
[OTHER]
AK- Alaska
AL- Alabama
AR- Arkansas
AZ- Arizona
CA- California
CO- Colorado
CT- Connecticut
DC- Washington DC
DE- Delaware
FL- Florida
GA- Georgia
HI- Hawaii
IA- Iowa
ID- Idaho
IL- Illinois
IN- Indiana
KS- Kansas
KY- Kentucky
LA- Louisiana
MA- Massachusetts
MD- Maryland
ME- Maine
MI- Michigan
MN- Minnesota
MO- Missouri
MS- Mississippi
MT- Montana
NC- North Carolina
ND- North Dakota
NE- Nebraska
NH- New Hampshire
NJ- New Jersey
NM- New Mexico
NV- Nevada
NY- New York
OH- Ohio
OK- Oklahoma
OR- Oregon
PA- Pennsylvania
RI- Rhode Island
SC- South Carolina
SD- South Dakota
TN- Tennessee
TX- Texas
UT- Utah
VA- Virginia
VT- Vermont
WA- Washington
WI- Wisconsin
WV- West Virginia
WY- Wyoming
Vehicle Year
Select a Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990 or Older
Vehicle Make & Model
Vehicle Color
Tire Size:
Address of Origin
ZIP CODE:
Address of Destination
Notes, Landmarks, Mile Markers, nearby Cities, etc to describe your exact location?
Any Notes or Details For The Driver?
Upload Image Of Map (If Address Isn't Working)
Select a File
Tech:
100
Payment Method
CASH
CREDIT CARD
DEBIT
CASHAPP
ZELLE
APPLE PAY
GOOGLE PAY
VENMO
Service Price ($):
[OPTIONAL] EMAIL OPERATORS:
OPEN CALL LIST?
OPERATOR EMAIL #1
OPERATOR EMAIL #2
OPERATOR EMAIL #3
OPERATOR EMAIL #4
OPERATOR EMAIL #5
OPERATOR EMAIL #6
OPERATOR EMAIL #7
OPERATOR EMAIL #8
OPERATOR EMAIL #9
OPERATOR EMAIL #10
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