Form Center

2. 

   P.O. Box 199 Clinton, NC 28329
3. Car Seat Install Request
5. Name
6. Phone Number
8. Address
9. City
10. State, Zip Code
12. In effort to provide you with the most effective services possible, we would like to ask a few questions.
14. Have a child seat?

    1. YES
    2. NO
15. Have seat installed?

    1. YES
    2. NO
16. In date?

    1. YES
    2. NO
    3. UNKNOWN
17. Have previous install knowledge ?

    1. YES
    2. NO
19. Number of seats?
21. 1. Have any of the child safety seats in your vehicle been in a accident?

    1. YES
    2. NO
    3. UNKNOWN
22. 2. Do you have any knowlede of airbag systems present in your vehicle?

    1. YES
    2. NO
23. 3. Are you aware of any recalls on your child safety seat models?

    1. YES
    2. NO
24. 4. In the event that your child safety seat is not safe to use, are you able to obtain another one?

    1. YES
    2. NO
26. Please provide any additional information in the box below
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

* indicates a required field