Brake System Evaluation Customer Diagnostic Survey Form
Customer Name *
Date *
MM
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DD
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License Plate #
VIN
Concern is Occurring...
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Are the Dash Warning Lights On
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Are the Brakes Making Noise
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When the Concern Occurs
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How Does the Brake Pedal Feel
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If shutters at high speed, at which speed does this begin? (km/hr)
Outside Temperature
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The Concern Started
MM
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DD
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YYYY
Describe the Concern
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