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Personal Information (View our privacy statement)
1)	First Name *
2)	Last Name *
3)	Street Address
4)	Address 2 (Apt. No)
5)	City *
6)	State *
7)	Zip Code (5 digits) *
8)	Phone
9)	Fax
10)	Email Address *
Vehicle Information
11)	Vehicle Make *
12)	Vehicle Model *
13)	Model Year (yyyy) *
14)	Was the vehicle purchased or leased?
15)	Was the vehicle new or used?
16)	Date contract was signed (mm/dd/yyyy) leave blank if you don't know
17)	Are you still making payments on the vehicle?
18)	If not, what was the date of your last payment (mm/dd/yyyy) leave blank if you don't know
19)	Name of Dealership
20)	Dealership Address (if known)
21)	Dealership City
22)	Dealership State
23)	Did you seek outside financing or use financing available from a bank or loan company through the dealership?
24)	If outside financing, have you ever seen the paperwork filed on your behalf with the lending institution?
25)	Do you have the purchase papers and contracts for this vehicle?
26)	Do you have the dealer/manufacturer new car window sticker on this vehicle at the time of purchase?
27)	If you paid for the vehicle with a loan, were the number of payments or interest rate on the purchase altered without your consent?
28)	Have you noticed any undisclosed charges, services or products on your contracts?
29)	If yes, which contracts and what service(s) or product(s)?

30)	Were there any services or products offered to you "free of charge"?
31)	If yes, what service(s) and/or product(s)?

32)	Were there in fact charges for these services in the purchase papers?
33)	Was "etch" (etching of a number on the window that identifies the vehicle) added to your contract?
34)	If yes, was a charge for "etch" disclosed to you?
35)	Did you take "spot" delivery of the car (delivery before the final finance contract was signed)?
36)	If so, did the terms of the contract change after you left the dealership?
37)	If yes, what was the change?

38)	Did the contract or contracts include a mandatory arbitartion clause (language requiring any dispute to be resolved through the use of arbitration)?
39)	Were you asked to sign paperwork that was blank or largely blank?
40)	If you purchased or leased a new vehicle, were you told whether or not it qualified for a rebate or cash back?

41)	May we contact you in the future to provide further information to you regarding this issue? *
42)	Do we have permission to share this information with law enforcement authorities (and no other party)? *
43)	Other Comments?

44)	Do we have permission to share your story as part of our public education effort, with your identifying information removed? *
* denotes a required field

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