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  1. Name & Address:    
    *Title
       *First     Initial    *Last    
    *Street
       Apt 
    *City
       *State/Prov 
    *Zip/Postal
        E-mail 
  2. Your date of birth:   
  3. Marital status:  
  4. *Date of purchase:           
  5. Model number:   
  6. Name of store where purchased:   
  7. Price Paid (excluding sales tax):$   .00
  8. Which Automate product did you purchase?  
  9. In what vehicle will this product be used?

    Vehicle type:  
    Make of vehicle: Bought new
    Model name: Bought used
    VIN# : Lease
    Year: Leased used
  10. How did you first become aware of this product?  
  11. What factors most influenced the purchase? (check up to three)




  12. What benefits most influenced your decision to purchase this product? (check up to three)




  13. What other brands did you seriously consider before making this purchase? 



    

 


  Failure to return this card will not diminish your warranty rights.