Request Service Form

Company Name

Customer Name*

Phone Number*

E-mail*

Is Pick-up / Delivery or On-Site Service Required? YesNo

Car Manufacturer

Serial Number

Have you previously purchased from CGC?

Billing Address*

City*

State*

Zip Code*

Electric or Gas Powered? ElectricGas

Does the car currently run? YesNo

Service Needed*

Security Question

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