Confirmation of Client Information for Filing of CA Complaint

*If More Than 1 Car, Please "Refresh" and Submit Multiple Forms:

Email:

Home Address - Street (Ex. 1234 Cherry Lane, Apartment 4B):

Home Address - City (Ex. Beverly Hills):

Home Address - County (Ex. Los Angeles):

Home Address - ZIP (Ex. 90210):

Nissan Model (Ex. Sentra, Versa, Rogue, Altima, Pathfinder, Murino, Maxima, etc.):

Year of Car:

TOTAL CVT Trans. Repair Attempts (Add together: Actual Repairs (regardless if the repairs were made under the original warranty or not) + # of times you took the car in with complaints but were turned away):

Purchased or Leased:

New or Used:

Still own Car?

Approximate Mileage (OPTIONAL):

Names of ALL Persons On Vehicle Registration:

State Car Purchased/Leased:

Selling Dealer Name:

Names of ALL Servicing Dealers OTHER Than Selling Dealer (if NONE, type "NONE"):

Notes to us (OPTIONAL):

SUBMIT