Contact Information:
* Name:
* E-Mail:
* Phone (Day):
Phone (Eve):
Address:
City:		State:	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
Zip:
* Please enter at least one phone contact.
Vehicle Information:
Year & Make:	Select Year 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 / Select Make Acura Audi BMW Buick Cadillac Chevrolet Chrysler Daewoo Dodge Eagle Ford GMC Honda Hyundai Infiniti Isuzu Jaguar Jeep Kia Land Rover Lexus Lincoln Mazda Mercedes Mercury Mitsubishi Nissan Oldsmobile Plymouth Pontiac Porsche Saab Saturn Subaru Suzuki Toyota Volkswagon Volvo
Model:		Current Mileage:
Date of Purchase:		New/Lease/ Used ?	Select Purchase Type New Used Demo Leased
Warranty Type:	Select Warranty Type New Car Warranty Extended Warranty Service Contract Dealer Warranty No Warranty - "AS-IS"

Defect and Repair Information:
Complaint / Defect	# of repair attempts	Does the problem still exist?
Engine, Transmission	0 1 2 3 4 5 +
Brakes	0 1 2 3 4 5 +
Steering & Suspension	0 1 2 3 4 5 +
Electrical System	0 1 2 3 4 5 +
Body, Paint & Interior	0 1 2 3 4 5 +
Heating/ AC	0 1 2 3 4 5 +
Leaks	0 1 2 3 4 5 +
Noises	0 1 2 3 4 5 +
	0 1 2 3 4 5 +

The total number of days the vehicle has been in the shop for all problems:    Select 0-15 16-29 30-45 Over 45

Comments / Additional information:

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