BENDERS AutoCare Make an Appointment Appointment Request Please take a moment to complete this form. Once our service advisor receives it, we will contact you to confirm your appointment time or arrange another time if your requested time was not available. Name* Daytime Phone * Alternate Phone Address Email * Zip Code City State Date/Time Requested Time Slot (Date - 1st Choice*) Select an OptionEarly AMMid MorningLate MorningAround NoonEarly AfternoonMid AfternoonExact Time, specify Time Slot (Date - 2nd Choice*) Select an OptionEarly AMMid MorningLate MorningAround NoonEarly AfternoonMid AfternoonExact Time, specify Prefer Date Prefer Time Best Contact Method EmailPhoneAlternate Phone Will you be waiting or need a ride? I would like to wait in your waiting roomI would like to arrange a shuttle rideI have a ride Vehicle & Service Information Describe problem and or services needed*