First Name:
Last Name:
Home Phone: (Ex: 555-555-5555)
Work Phone: (Ex: 555-555-5555)
Cell Phone: (Ex: 555-555-5555)
Email:
Best Time To Reach You:
Morning - AM Afternoon - PM
Best Way To Reach You:
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Address:
City:
State:
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Zip Code:
Referral:
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Vehicle Make:
Vehicle Model:
Vehicle Year:
Date of Purchase: (Ex: 01/01/2001)
Current Mileage:
Did you buy your vehicle from a Dealer or Private Party?
Dealer Private Party
Did you buy your vehicle new or used?
New Used
Did you purchase or lease your vehicle?
Purchase Lease
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?
What is the third biggest problem with your vehicle?
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?
No Yes
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
Disclaimer: Submission of this form is for consultation and does not create an attorney-client agreement
