DOT Date Code Mount Refusal Acknowledgment Form

Documents when an installer refuses to mount a customer-supplied tire that exceeds the store's DOT date-code policy and captures the customer's acknowledgment.

Customer and Vehicle Information

• Customer Name
• Contact Phone
• Vehicle Identifier
  Enter the license plate, work order number, or last 6 of VIN if used by your shop.
• Service Date
• Service Advisor / Installer

Tire Details

• Tire Position
• Tire Brand / Model
• Tire Size
• DOT Date Code
  Enter the DOT date code if visible. Do not collect more tire data than needed.
• Is the DOT date code visible?

Refusal Reason and Policy Basis

• Reason for Refusal
• Store Policy Reference
  Enter the internal policy name, date, or reference used for the refusal.
• Was a manager notified?
• Manager Name

Customer Acknowledgment

• Acknowledgment Statement
  By signing, the customer acknowledges that the tire was not mounted due to the store's DOT date-code or safety policy and that the decision was explained before service completion.
• Alternative Service Offered
• Customer Comments
  Optional notes from the customer. Avoid collecting unnecessary PII.
• Customer Signature
• Signature Date