Free Lemon Evaluation Form

Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

Vehicle Make Model and Year

Select any of the following options that apply:

New        Used       Purchased  Leased   

Selling Dealer

Purchase Price

Enter the date of Purchase

-- mm/dd/yy

Mileage

What is your vehicle used for?

Personal Business

Duration of basic warranties

Duration of Extended Warranties

Was vehicle ever in any accidents?

Yes No

Describe defects and number of times repaired for each

IF you believe you are a victim of Fraud, Explain why.