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ABOUT YOU

Name*

Email Address*

Address*

City*, State*, Zip*


Daytime Phone Number*

Evening Phone Number

ABOUT YOUR VEHICLE

Year

Make

Model

Date of Purchase
Month Year

Was you vehicle:
Leased or Purchased

Approximate Mileage when you received it?

Approximate Mileage now:

Has you vehicle been wrecked or damaged while you have had it?
Yes or No

ABOUT YOUR PROBLEMS

About how many times has your vehicle been in the dealer's repair shop for warranty work?

About how many calendar days has your vehicle been out of service because of repair work?

In the spaces provided, please list each problem that your vehicle has experienced, the number of trips to dealer for each, and whether you think it is fixed now.

Problem #1
Number of Trips to Dealer
Fixed now?: Yes No Don't Know

Problem #2
Number of Trips to Dealer
Fixed now?: Yes No Don't Know

Problem #3
Number of Trips to Dealer
Fixed now?: Yes No Don't Know

Problem #4
Number of Trips to Dealer
Fixed now?: Yes No Don't Know

Do you think the dealer lied to you about the vehicle?
Yes No Don't Know

If yes, why?

Please provide any additional information you'd like to add.