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CUSTOMER INFORMATION

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First Name: *

Middle Initial:

Last Name: *

Address: *

Zip Code: *

City: *

State: *

Email Address: *

Phone (Main): *

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Comments and Instructions

Appointment Date and Time

Discount Wheel and Tire customer service will contact you as soon as possible for an appointment.

We recommend you arrive 10-15 minutes prior to your scheduled appointment time.

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CUSTOMER INFORMATION

Comments and Instructions

Appointment Date and Time