ACT Assistance Form

Date*

Name (First and Last)*

Phone #*

Email Address*

Vehicle Information

Year*

Make*

Model*

Torque Produced (at the crank)*

Type of Driving*

Select

Part # Owned or Interested In (If applicable)

Date of Purchase (If applicable)

Where Purchased

Receipt?

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Question or Issue Type*

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Description of Issue*

File Attachments (Any applicable pictures or video)

Drag and drop files here or

Preferred Contact Method

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Best Time to Contact (Please include time zone)

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