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AMP Customer Intake Form

CUSTOMER DROP-OFF

AMP Customer Intake Form

Please complete this form before leaving your e-bike, scooter, e-moto, battery, or other unit with AMP.

Customer Information

Full Name * Phone Number * Email Address * Address City / State / ZIP Job Number

How did you find AMP? *

Unit Information

Unit Type Make / Brand Model Color Serial Number Tire Size Voltage Motor Type Controller Location

Customer Complaint Describe the issue in your own words * What happened right before it failed?

Water exposure Crash / impact Sat unused Error Code

Items Left With AMP

Charger included Keys / NFC card Accessories removed Intake photos taken

Other items or visible pre-existing damage

Service Requested

Diagnostic Repair Battery rebuild Tire / tube Tune-up Pickup / delivery

Special Instructions

Policy Acknowledgement and Signature

The diagnostic fee is separate from repair costs and is due at drop-off. Quotes expire after 7 days. After 14 days with no response, storage fees may apply. AMP is not responsible for pre-existing damage. Customer-supplied parts carry no labor warranty. Pickup/delivery is $50 per leg.

I have read and agree to these terms and authorize AMP to perform the requested diagnostic and service evaluation. *

Type Full Legal Name as Signature * Signature Date *

AMP Staff Use

Diagnostic Fee Collected Payment Method Estimated Ready Date

AMP Electric Wheelz | 678-201-0808 | ampelectricwheelz.com

AMP Electric Wheelz Shop 10am-2pm M-F Appointment

100 Paper Mill rd
lawrenceville ga
Suite E-3

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