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