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Customer Information and Instructions Form
Thank you for considering Emergency Road Services Corporation as a part of your emergency road service solutions team. Imagine having to make just one call for any type of breakdown and having E.R.S. Corp. get you back on the road as quickly and as cost effectively as possible throughout Canada and the U.S.A.

Put the power of E.R.S. Corp. to work for you and your business by becoming an E.R.S. Corp. customer today.

E.R.S. Corp. will provide you with the best support when you need it the most. Whether you need a mechanic, tire service or a tow, E.R.S. Corp. will be there for you 24 hours a day, 365 days a year. We can also help you if you run out of fuel, your truck won’t start or you have locked yourself out of your vehicle, as our extensive network of service providers across North America covers every type of breakdown.

Becoming an E.R.S. Corp. customer is quick, easy and best of all, FREE! Below you will find our ‘Customer Information and Instructions Form’ and our ‘Terms and Conditions’. You are asked to complete a series of questions designed to convey your company’s service call needs and specific instructions to the E.R.S. Corp. management team. After completing the form, please click the ‘Submit’ button.

Once you have submitted your FREE application to become a customer, a member of E.R.S. Corp.’s management team will contact you. If you have any questions or if you would like to request additional information, please call 905-277-2377 or Toll Free at 1-866-MY-ERS-24/7, (1-866-693-7724).

*Note: Questions that are in red text are required fields.
Company Name

Customer Name

Company Address
Title
City
Phone
Province
Fax
Postal Code
E-mail
Country

Website

1. Do you maintain offices or facilities other than what is listed above?
Yes No
If yes, please list addresses. Location 2:
Location 3:
Location 4:
2 .How many trucks does your company operate?
3. How many trailers does your company operate?
4. Does your company operate any other type of equipment?
Yes No
If yes, please specify:
5. Please specify who is authorized to call E.R.S. for emergency road services.
1.
2.
3.
4.
5.
6. Does your company issue purchase order numbers?
Yes No
If yes, please check the following that applies:
P.O to be issued before repairs
P.O to be issued after repairs
P.O to be issued after billing information is available
7. Would you like to be notified if a repair or service call exceeds a certain amount?
Yes No
If yes, what is the amount excluding taxes?
(all repairs above this amount will require authorization)
8. Would you like to be notified when repairs or services are completed?
Yes No
If yes, how would you like us to notify you ?
Telephone Telephone Number

Email Email Address
9. If you have any other instructions or requirements, please state them here:
10. Please specify names of people who can authorize repairs or services above your authorized limit.

Daytime

Name: Phone # Cell #
Name: Phone # Cell #
Name: Phone # Cell #

After Hours/Weekends/Holidays

Name: Phone # Cell #
Name: Phone # Cell #
Name: Phone # Cell #

11. If we can not reach any of the above authorized people when a repair or service is above your authorized limit, would you like us to continue with the repair or service, or would you like us to cancel the service call until the next morning?
Continue with repair or service call

Cancel Service Call
12. If after all efforts, E.R.S. is not able to carry out the service call, who would you like us to contact?
Daytime

Name: Phone # Cell #

After Hours/Weekends/Holidays

Name: Phone # Cell #

13. Does your company prefer a certain brand of tire?
Yes No
If yes, please specify brand by location:

Steer axles :
Drive axles :
Trailer axles
14. What type of replacement tire do you prefer?
Brand New Re-cap
15. Does your company have a national account with a tire company?
Yes No
If yes, would you like us to use your account on your behalf?
Yes No

16. How did you hear about E.R.S.?

17. Authorization

Enter first name and last name in the boxes below:
I, hereby confirm that the above information, supplied by me is correct in every respect. Furthermore, I have read and fully understand and agree with your terms and conditions listed below. By clicking the Submit' button below, I confirm the above information and electronically sign and authorize Emergency Road Services Corporation, to process my application. If you do not enter your first and last name above, you will not be able to submit this form.



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Emergency Road Services Corporation is a Canadian based company which coordinates emergency break down services for the trucking industry throughout the United States and all ten Canadian provinces which include British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Quebec, Newfoundland, Nova Scotia, New Brunswick and Prince Edward Island. Our 24 hour services include emergency road side truck repairs, trailer repairs, tire repair or replacements, towing (heavy, medium and light duty) and recovery services, reefer/heater repairs, boost (no-start) services, lock-out services and fuel delivery (diesel or gas). Our mission is to provide the fastest, most cost effective emergency road services in Canada and the United States in order to reduce our customer’s downtime and operating expenses. When you think of Emergency Road Services Corporation, think of us as a part of your emergency road services solutions team.