Contact Information:
*First Name:
*Last Name:
Address 1:
Address 2:
*City:
*State:
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*Zip:
*Email:
*First Phone:
Home
Work
Cell/Pager
Second Phone:
Home
Work
Cell/Pager
Third Phone:
Home
Work
Cell/Pager
Comments:
Referred By:
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CarLemon.Com
Google
MSN
Yahoo
Other Search Engine
Other Web Site
If Other:
Vehicle Information:
Manufacturer:
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Acura
Audi
BMW
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Cadillac
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Model Year:
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2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
Model:
Purchase Date:
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Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
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2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
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1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
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1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Type of Purchase:
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New
Used
Lease
State of Purchase :
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
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Maryland
Massachusetts
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Ohio
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Pennsylvania
Rhode Island
South Carolina
South Dakota
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Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Current Mileage:
Purchase Mileage:
Dealer:
Warranty:
Select
New Car Warranty
Extended Warranty
Dealer Warranty
No Warranty- 'AS IS'
Repair Information:
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0
1
2
3
4
5 +
Total Number of Repairs
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1-10
11-20
21-30
31-40
40 +
Total Number of Days in the Shop
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0
1
2
3
4
5 +
- Brakes, Steering or Suspension
Select
0
1
2
3
4
5 +
- Engine or Transmission
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0
1
2
3
4
5 +
- Electrical System
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0
1
2
3
4
5 +
- Heating or Air Conditioning
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0
1
2
3
4
5 +
- Fluid Leaks
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0
1
2
3
4
5 +
- Unusual Noises
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0
1
2
3
4
5 +
- Body, Paint or Interior
Select
0
1
2
3
4
5 +
- Other
Additional Information:
Other Vehicle Concerns:
No
Yes
Do you suspect the Odometer may have been altered prior to your purchase?
No
Yes
Do you think the Vehicle may have been in an accident prior to your purchase?
List any other concerns related to the purchase or repair of your vehicle.
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