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Run: DOT Date Code Mount Refusal Acknowledgment Form

Use this form to document when a customer-supplied tire is refused because its DOT date code falls outside store policy, and to capture the customer’s acknow...

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Customer and Vehicle Information

Customer Name (required)

Contact Phone

Vehicle Identifier (required)

Enter the license plate, work order number, or last 6 of VIN if used by your shop.

Service Date (required)

Service Advisor / Installer (required)

Tire Details

Tire Position (required)

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? (required)

Refusal Reason and Policy Basis

Reason for Refusal (required)

Store Policy Reference (required)

Enter the internal policy name, date, or reference used for the refusal.

Was a manager notified? (required)

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 (required)

Signature Date (required)

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Email (required)

Your name (optional)

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