Wheel Collision Center
231 Moorestown Dr. Bath, PA 18014
800-292-7467
E-Mail
Name
Company
Street
Street
City
State
Zip
Daytime Telephone
Evening Telephone
Fax
Vehicle #1
Year
Make
Model
Quantity
1
2
3
4
Size
Description
Vehicle #2
Year
Make
Model
Quantity
1
2
3
4
Size
Description
Straighten Only, If Possible
Refinish Only, If Possible
Chrome or Rechrome Wheels
Repair + Refinish
Custom Polish
Refinish Back of Wheel
Refinish Center Caps
Custom Paint
Paint Code Description
Core Wheel Return
Core Return Number (Call)
Warranty Wheel Return
Warranty Return Number (Call)
Discard Tires
Remount and Balance Tires
Provide Pricing on New Tires
Other
How did you find out about us?
Internet
Car & Driver
Roundel
Modern Tire Dealer
Road & Track
Panorama
Car Buyer's Guide
Auto Week
Vette
Referral
European Car
Star
Trade Show
Other
PLEASE: Include a printed copy of this form when shipping wheels for repair/refinish for more efficient handling.