Eagle Tele-Services, Inc. • 1748 East Parham Road • Richmond, VA. 23228

                  Phone: 804-545-1803 • Fax: 804-515-9078 •

1.
Eagle Tele-Services, Inc.
Customer Setup Authorization

Company Name: ___________________________________________________________________
Address: _____________________________ City_________________State_______Zip________
Company Phone: __________________________ Company Fax: __________________________________
Main Contact Name: _______________________________________________________________________
Contact Phone: ___________________________ Contact Fax: ___________________________________
Billing Contact Name: ______________________________________________________________________
Billing Contact Phone: ______________________ Billing Contact Fax:______________________________
Shop/Maintenance Phone: ___________________
Approximate Number of Fleet Tractors__________Trailers____________Other____________

Authorization of service:
The system generated incident number will be used as the PO (purchase order) and/or reference number for all
incidents handled. Customers do have the option to assign an open PO which can be used as an internal reference
for the fleet. ETS will contact the customer for authorization of repairs that will exceed $750. If there is nobody
available to provide authorization, ETS should ____ continue with service or _____ delay service until
authorization is provided (check the appropriate process).

Standing PO number _______________ (To be used on incidents up to the authorized amount.)

To obtain authorization for repairs exceeding $750 please call the following list:
During normal business hours Hours: ____ AM/PM - ____ AM/PM EST
Contact 1: ________________________ Title: __________________
Number: ________________________ (Home Office Cell Pager)
Alt Number: _____________________ (Home Office Cell Pager) (Circle)
Alt Number: _____________________ (Home Office Cell Pager)

Contact 2: ________________________ Title: __________________
Number: ________________________ (Home Office Cell Pager)
Alt Number: _____________________ (Home Office Cell Pager) (Circle)
Alt Number: _____________________ (Home Office Cell Pager)

Contact 3: ________________________ Title: __________________
Number: ________________________ (Home Office Cell Pager)
Alt Number: _____________________ (Home Office Cell Pager) (Circle)
Alt Number: _____________________ (Home Office Cell Pager)




2.
After hours and weekends Hours: ____ AM/PM - ____ AM/PM EST
Contact 1: ________________________ Title: __________________
Number: ________________________ (Home Office Cell Pager)
Alt Number: _____________________ (Home Office Cell Pager) (Circle)
Alt Number: _____________________ (Home Office Cell Pager)

Contact 2: ________________________ Title: __________________
Number: _________________________ (Home Office Cell Pager)
Alt Number: _____________________ (Home Office Cell Pager) (Circle)
Alt Number: _____________________ (Home Office Cell Pager)


Please Collect the following required data for each incident: (Check all that apply)
! Defective Unit # ! Mileage
! Associated Unit # ! VIN/Serial #
! Driver Name ! DOT on/off
! Reason for Failure !

AUTOMATED NOTIFICATION
Please send me an email:
! When Incident is opened
! When Incident is completed

To what email address should we send these notifications? ________________________________

TIRE SERVICE
Unless otherwise noted, all tires will be replaced with new tires of the same brand, type and size, if possible.

Tire Preferences: (If possible replace tires with the following:)
• Replace Steer Tire with: ! New ! Used
• Replace Drive Tire with: ! New ! Used ! Recap
• Replace Trailer Tire with: ! New ! Used ! Recap

Use the following tire national accounts, if possible:

1. Company: Bridgestone _________ Account #: ___________________

2. Company: _____________________________ Account #: ___________________

3. Company: _____________________________ Account #: ___________________

4. Company: _____________________________ Account #: ___________________

5. Company: _____________________________ Account #: ___________________



Disposition of removed tire parts:

! Return to Driver ! Disposed of by service provider ! Ship to terminal

MECHANICAL SERVICE (If applicable to this program)

Mechanical national accounts: (list in order of preferred use)

1. Company: ____________________________ Account #: ___________________

2. Company: ____________________________ Account #: ___________________

3. Company: ____________________________ Account #: ___________________

4. Company: ____________________________ Account #: ___________________

5. Company: ____________________________ Account #: ___________________

Debit Account Information:
If a service is provided that cannot be charged to one of your national account programs, what debit/charge
account should Breakdown Manager use to cover cost of repairs:

1. Company: ____________________________ Account Type: ___________________
Account #: ___________________________ Exp. Date: ______________________

2. Company: ____________________________ Account Type: ___________________
Account #: ___________________________ Exp. Date: ______________________

For the purpose of making payment or charges for vehicle repairs or other such services requested on behalf of

______________________________________________ I, ________________________________ authorize
(Company Name) (Printed Name of Authorizing Party)

Eagle Tele-Services, Inc. use of the account information included within this document.


Signature of Authorizing Party: __________________________________
Title: ______________________
Date: ______________________
Please return the completed form by fax to 804-515-9078 or by e-mail to mail@eagleteleservices.biz