Personal Car Information Sheet

For us to get a better understanding of the problem with your vehicle, please complete the following information and our service manager will get in contact with you right away!

For your convenience, Cox Automotive offers free pickup and delivery within a 10 mile radius of our shop. Let us know your problem and how we can contact you by completing the following information.

Items in red are required information.

 
Name Daytime #
Email
Are you a repeat customer or a new customer?
If you are a new customer, please fill out the following:
Home Address City & Zip
Work Address City & Zip
Evening # Fax
Mobile # Other
Vehicle Information
License State
Have we worked on this vehicle before?   Yes No
If no, please complete the following:
Make Model
Year Color
Please describe the problem with your vehicle:
Where will you leave the vehicle?
Where will we find the key?
When shall we pick up the vehicle?
Month Day Time A.M. P.M.
Payment Method: Check Cash Credit Card


This is NOT a secure form. Do not include your credit card numbers.