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First Name *

Middle Name

Last Name *

Email Address *

Phone Number *

Size of Tire *

Type of Tire *

Photo of Tire (Side) *

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Type of Repair

Photo of Repair spot if visible *

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Type of Mechanic Issues *

Photo or Video of Mechanical Issue *

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Make of Vehicle *

Model *

Year *

Color *

Home or Office Address *

Pin Location

Coordinates

Mile Marker *

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