Vehicle Information:
Year:
Make:
Model:
Mileage:
Engine Size:
If other, please specify:

What is the transmission type?
Automatic   Standard

Is the check engine light on?
Yes   No

In the last six (6) months have you had any service done on the: (Check all that apply)
Engine   Axles 
Radiator   .Transmission    Other:

When was the last time the transmission was serviced?

Does the battery run down?
Yes   No

Experiencing a delay or have trouble going into drive or reverse when cold?
Yes   No

Experiencing a delay or have trouble going into drive or reverse when hot?
Yes   No

Any noise or shifting problems when accelerating?
Yes   No

Any noise or shifting problems when at a constant speed?
Yes   No    If yes, at what mile per hour? MPH

How long have you had any of the above problems?

How long have you owned the vehicle?

IMPORTANT! Describe any other symptoms or conditions:

*What Time of Day would you like to be contacted 8:00AM - 5:00PM

Contact Information:

NOTE: ALL FIELDS MARKED BY AN ASTERISK (*) MUST BE COMPLETED.

* First Name:
*Last Name:
*Day Time
Contact Number:

(Include Area Code)

Use only numbers.
* City:
*Zip:  
*Email Address:

....

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