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   Air Conditioning Radiator   .Transmission    Other:

When was the last time you had the vehicle was serviced?
Please choose Less than a month Less than 6 months Less than a year More than a year Never Don't know

Does the battery run down?
Yes   No

Experiencing engine problem?
Yes   No

Experiencing brake or drivability problem?
Yes   No

Any noise in the system?
Yes   No

Any 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?
Please choose Less than a week Less than 1 month Less than 6 months More than 6 months Don't know

How long have you owned the vehicle?
Please choose Less than 6 months More than 6 months

IMPORTANT! Describe any other symptoms or conditions:

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