New Customer Intake Form Please enable JavaScript in your browser to complete this form.Company Name as shown on Federal Tax Return *Alternate Company Name (DBA if applicable) *Business Physical Address *Truck location address (if different from physical address) *Is your company exempt from sales tax? *YesNo(If YES, please email us your company's Resale Certificate or Tax Exemption Certificate) Contact information for estimate:Full Name of person making overall decisions at this location *Email *Phone Number *Preferred Method of Communication *EmailPhone CallText MessageIf you would like text messages, please read the agreement below: *YesNoYes, I consent to receive real-time updates and share collision pictures and messages with CMD Box Truck Repair & Collision. Message and data rates may apply; messaging frequency may vary. Reply STOP to end. Adjuster (PO), Return If yes, what is the best number to text? *Contact information for Final invoice: (Please provide Accounts payable department contact information if applicable)Full Name *Contact information for Final invoice: (Please provide Accounts payable department contact information if applicable)Email *Phone Number *Preferred Payment Method *CheckCredit CardACH/ EFTPlease note their is a convenience fee of 3.1% for credit card transactions.Does your company provide a Purchase Order (PO), claim number, or reference number for approved repairs? *YesNoDo you Lease or Own Truck? *OwnLeasePlease provide the Unit # or Asset #, if applicable. *If your company does not utilize truck identification numbers, kindly indicate NA.VIN number *If VIN # not available, please provide License Plate # instead.Will this be an Insurance Claim? *YesNoIf YES, please provide the require information below. IMPORTANT: If you do not promptly inform us that the repair is an insurance claim, if may result in delays to both the estimate and the repair process.Is this a Fleet Management Provider Claim? *YesNoApplicable only to Fleet companies. If YES, please provide the required information below. If you do NOT promptly inform us that the repair is an insurance claim, it may result in delays to both the estimate and the repair process.Insurance or Fleet Claim Provider Company Name *Claim Number *Adjuster / Fleet Management Contact Name *Adjuster / Fleet Management Contact Email *Adjuster / Fleet Management Contact Phone Number *Marketing Photo Consent *I authorize CMD to use before/after repair photos of my vehicle for social media and marketing.I do not authorize.How did you hear about us? *Submit
