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Customer Information
Full Name
Phone
Email
*
City
Zip Code
Vehicle Information & Paint Condition
Year
Make
Model
Mileage
How would you describe the current condition of your vehicle’s paint?
New / Like New
Good - minor imperfections
Fair - visible scratches or swirls
Poor - significant wear or fading
Not Sure
Are there any specific paint concerns you want addressed? (Select all that apply.)
Water spots
Fading / oxidation
Deeper scratches
No specific concerns
Has this vehicle had any paintwork or collision repairs in the last 90 days?
Yes
No
Not sure
Vehicle Use
How long do you plan to keep this vehicle?
1 - 3 years
3 - 5 years
5 - 10 years
10+ years
Not sure
Is the vehicle typically garage kept?
Yes, most of the time
Sometimes
No, mostly outdoors
Which description best fits the vehicle?
Daily driver
Weekend / recreational vehicle
Classic / collector car
Show car / specialty vehicle
Coating & Protection Interests
Which services interest you? (Select all that apply.)
Exterior paint ceramic coating
Windshield glass coating
Wheel / rim coating
Interior protection (seats, carpet, surfaces)
Exterior plastic / trim protection
Not sure — please advise
Which exterior coating package interests you?
5-year coating
9-year coating
Not sure — please recommend one
Additional Details
Anything else you would like us to know?
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Ceramic Coating
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Dieterich: (217) 925-5331Flora: (618) 662-5641 Dieterich: (217) 925-5331Flora: (618) 662-5641