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| Contact Information: |
| *First Name: | | |
| *Last Name: | | |
| Address 1: | | |
| Address 2: | | |
| *City: | | |
| *State: |
*Zip: | |
| *Email: | | |
| *First Phone: | | | |
| Second Phone: | | | |
| Third Phone: | | | |
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| Vehicle Information: |
| Manufacturer: | | |
| Model Year: | | |
| Model: | | |
| Purchase Date: | | |
| Type of Purchase: | | |
| State of Purchase : | | |
| Current Mileage: | | |
| Purchase Mileage: | | |
| Dealer: | | |
| Warranty: | | |
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| Repair Information: |
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Total Number of Repairs
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Total Number of Days in the Shop
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- Brakes, Steering or Suspension
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- Engine or Transmission
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- Electrical System
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- Heating or Air Conditioning
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- Fluid Leaks
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- Unusual Noises
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- Body, Paint or Interior
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- Other
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| Other Vehicle Concerns: |
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Do you suspect the Odometer may have been altered prior to your purchase?
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Do you think the Vehicle may have been in an accident prior to your purchase?
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List any other concerns related to the purchase or repair of your vehicle.
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Submitting this form does not establish an attorney/client relationship – that will be established only upon our mutual agreement and execution of an agreement. Weisberg & Meyers, LLC has attorneys admitted to practice in Arizona, California, Colorado, Florida, Illinois, New Mexico, Oklahoma, Oregon, Texas and Washington and works with a nationwide network of consumer advocates in all other states. Accordingly, inquiries/submissions may be referred to and services may be performed by other attorneys associated with Weisberg & Meyers, LLC. As such, information sent in a request for a brochure/information may not be kept confidential and may not be protected by the attorney/client privilege, however, any such information will not be disseminated in any way or for any purpose other than that stated above.
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