First Name

Last Name

Home Phone Number

Work Phone Number

Cellular Phone Number

E-Mail

Best time to reach you.

Best way to reach you.

Mailing Address

City

State

Zip Code

Referral

Vehicle Make

Vehicle Model

Vehicle Year

Date of Purchase

Current Mileage

Did you buy your vehicle from a Dealer or Private Party?

Did you buy your vehicle new or used?

At what dealer did you purchase your vehicle?

What is the biggest problem with your vehicle?

How many times has this problem been repaired?

What is the second biggest problem with your vehicle?

How many times has this problem been repaired?

What is the third biggest problem with your vehicle?

How many times has this problem been repaired?

How many total days has your vehicle been out of service?

How have the problems with your vehicle impaired your use of the vehicle?

Do you believe your odometer was tampered with?

Do you believe your vehicle was involved in an accident prior to your purchase?

Do you believe that you were the victim of any other type of fraud involving your the purchase of your vehicle?

Please tell us any other concerns you have with your vehicle.