Wheel Collision Center
231 Moorestown Dr. Bath, PA 18014
Name Company
Street City
State Zip
Daytime Telephone Evening Telephone Fax

Vehicle #1 Year Make Model
Quantity Size Description
Vehicle #2 Year Make Model
Quantity 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

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.