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Run: Wiper Blade Free Installation Service Waiver Form

A waiver form for free wiper blade installation that records customer and vehicle details, captures pre-existing damage disclosures, and documents consent be...

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Service Acknowledgement

I understand this is a free wiper blade installation service and that the store is not responsible for pre-existing damage to the wiper arms, windshield, or related components. (required)

Yes No N/A

I consent to the store performing the installation service on my vehicle. (required)

Yes No N/A

What happens after I submit?

A store associate will review your waiver, confirm the vehicle details, and then complete the free installation if the service can be performed safely.

Customer and Vehicle Details

Customer Name (required)

Phone Number

Optional contact number if we need to clarify vehicle fitment or service details.

Vehicle Year (required)

Vehicle Make (required)

Vehicle Model (required)

License Plate Number

Optional, for internal service record matching only.

Pre-Existing Condition Disclosure

Are you aware of any pre-existing damage or issues with the wiper arms, wiper linkage, windshield, or mounting hardware? (required)

Describe the pre-existing damage or issue

Include only what is relevant to the installation, such as cracked glass, bent arms, seized clips, or missing hardware.

I understand the store may decline or stop the installation if existing damage or unsafe conditions are found. (required)

Yes No N/A

Signature and Record

Customer Signature (required)

Date (required)

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Email (required)

Your name (optional)

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