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    COVID-19 Customer Policy

    Photo of ID/Payslip/Letter (gif, png, jpg, pdf)
    [file file-914 filetypes:gif|png|jpg|jpeg|pdf]

    Employer Details:

    Employer Name (Person we need to ring)
    [text employerName]
    Employer Phone
    [tel employerphone]
    Company Name
    [text employerCompany]

    [checkbox* checkbox-861 “I agree that the information given is correct”]

    2. COVID-19 Health Declaration

    Full Name
    [text* fullName]

    Contact Phone
    [tel* phone]

    [email* email]

    1. Symptoms

    Have you had any of the following?
    [checkbox checkbox-44 “Cough” “Shortness of breath” “Sore throat” “Fever (38ºC or higher)”]

    2. Recent travel or contact with someone with novel coronavirus

    Have you travelled to or from (excluding airport transit through) countries or areas of
    concern within 14 days before onset of illness?

    [radio radio-45 default:2 “Yes” “No”]

    If Yes, please provide details
    [text travelDetails]

    Have you been in close contact or casual contact with a person with suspect, probable or confirmed
    infection of novel coronavirus in the 14 days before the onset of your symptoms?

    [radio radio-46 default:2 “Yes” “No”]
    If Yes, please provide dates of contact
    [text contactDetails]

    [checkbox* checkbox-862 “I agree that the information given is correct”]

    3. Repair / Warrant of Fitness Sheet

    If you have been given any kind of paperwork related to repairs, please attach a photo/scan of the sheet here, email the photo tonyv@grimmermotors.co.nz, or leave it in your vehicle on the passenger seat when you drop the car off.

    [file file-914 filetypes:gif|png|jpg|jpeg|pdf]

    [checkbox* checkbox-863 “I agree that the information given is correct”]

    4. Your Electronic Signature

    Your signature to confirm you agree to the terms and conditions listed above,
    as well as having filled out the form truthfully and to the best of your ability.
    By typing your full name into the box below, you agree that this is your Electronic Signature,
    the same as if you where handwriting your signature
    This is a legal document and all information is required to be held and provided to the New Zealand Government on request.
    Any false declaration will be breaking the law.

    [text* signature]
    [submit “Submit”]

    Grimmer Motors Hamilton “[fullName]” Customer Policy
    From: [fullName] <[email]>
    Subject: [fullName] Customer Policy

    Message Body:
    Full Name: [fullName]
    Phone: [phone]
    Email: [email]
    Symptoms: [checkbox-44]
    Travel to other countries? [radio-45] [travelDetails]
    Close contact with COVID-19 case(s)? [radio-46] [contactDetails]

    Terms Comments: [TermsComments]

    1. [checkbox-861]
    2. [checkbox-862]
    3. [checkbox-863]
    4. [checkbox-864]

    Signature: [signature]

    Employer Details:
    Name: [employerName]
    Company: [employerCompany]
    Phone: [employerphone]

    This e-mail was sent from a contact form on Grimmer Motors Hamilton (https://grimmermotors.dev.voyle.nz)
    Reply-To: [email]

    Grimmer Motors Hamilton “[your-subject]”
    Grimmer Motors Hamilton
    Message Body:

    This e-mail was sent from a contact form on Grimmer Motors Hamilton (https://grimmermotors.dev.voyle.nz)
    Reply-To: tonyv@rennacs.com

    Thank you for your message. It has been sent.
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    Phone: 07 855 2037

    Email: office@grimmermotors.co.nz

    Address: 998 Heaphy Terrace, Fairfield, Hamilton

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