Vehicle Jack Extension Request Form
Submit your request to extend the use of a vehicle jack. Please complete all sections for prompt processing.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Department or Unit
Vehicle Make
*
Please Select
Ford
Chevrolet
Toyota
Honda
Nissan
Dodge
Other
Vehicle Model
*
Vehicle Year
*
Vehicle Identification Number (VIN) or Asset ID
Jack Type
*
Scissor Jack
Hydraulic Jack
Bottle Jack
Floor Jack
Other
Jack Serial Number or Asset Number
Reason for Extension Request
*
Ongoing repairs
Awaiting parts
Scheduling conflict
Unexpected delay
Other
Required Extension Length (days)
*
Pickup/Needed-By Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Requested Return Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Notes or Special Instructions
Submit Request
Should be Empty: