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Appointment Request Form
Use this form to request a service appointment.
Vehicle Information
*
Manufacturer :
*
Year :
*
Model :
*
Miles :
VIN Number :
Was your vehicle
Purchased, or Previously serviced here? :
Yes :
No :
Transportations Arrangements
; Will you be :
Make Selection
Waiting
Dropping Off
Requiring Shuttle Service
Rental Vehicle
Service Information
*
Type of Service Needed :
Make Selection
Periodic Maintenance Inspection (PMI)
Change Oil & Filter
GM - Maintenance I
GM - Maintenance II
Rotate Tires
Rotate & Balance 4 Tires
Front End Alignment
Four Wheel Alignment
Transmission Service
Cooling System Service
Adjust Brakes
Adjust Clutch
Replace Wiper Blades
State Inspection
Emission Test
Install Order Part
Tune-Up
Check Oil Leaks
Check Coolant Leaks
Check Transmission Leaks
Check Engine Light On
Dash Board Light On
ABS Light On
Ride Control Light On
Reline Brakes
Check Exhaust System
Special Requests :
*
Preferred Appointment Time and Date :
Date :
Pick Date
8:00
9:00
10:00
11:00
12:00
1:00
2:00
3:00
4:00
*
Alternate Appointment Time and Date :
Date :
Pick Date
8:00
9:00
10:00
11:00
12:00
1:00
2:00
3:00
4:00
Contact Information
*
Name :
*
Email :
*
Home Phone :
*
Day Phone :
Fax:
Preferred Contact:
Phone Morning
Phone Midday
Phone Evening
Email
Fax
*
Address:
*
City:
*
State:
*
Zip:
*
These fields are required
Bethlehem Ford
PO Box 4429, Bethlehem PA 18018 Ph: 610 867-8641 toll free: 800 639-3673
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