Warranty Card To validate warranty this form must be filled out completely within 5 days of installation. Part Number (required) Serial Number (required) Install date Owner Name (required) Owner Address Owner City Owner State Owner Zip Code Country Owner Phone Number Owner Email Dealer Name Dealer Contact (required) Dealer Number Dealer Address Dealer City Dealer State Dealer Zip Code Dealer Country Dealer Phone Number Dealer Fax Number Dealer Email Dealer Web Address Mounting Information Please indicate which bracket was used on the installation of hand control (if applicable) Brackets68621 GM Bracket68622 Ford Bracket68623 Ford T Bird Bracket68624 Ford Torino Bracket68625 Omni/Horizon Bracket68627 Slotted Version Bracket68628 Taurus/Sable Bracket68640 Clamp-on Univ. Bracket68657 Bolt-on Univ. Bracket68665 Strap-on Univ. Bracket68726 1997 - 2008 Ford FS Van Bracket68749 Honda Element w/ Lower Floor68753 2009 & Newer Ford FS Van69759 2001 Caravan Bracket69760 2003 Chevrolet Venture69767 2005 Caravan Bracket69769 2005 Toyota Sienna69774 2006 Caravan Bracket69780 2008 Caravan Bracket68661 Bolt-on "Y" Bracket "A"68662 Bolt-on "Y" Bracket "B"68663 Bolt-on "Y" Bracket "C"68664 Bolt-on "Y" Bracket "D"68727 Bolt-on "Y" Bracket "E"68728 Bolt-on "Y" Bracket "F"68747 Bolt-on "Y" Bracket "G"68751 Bolt-on "Y" Bracket "H"68756 Bolt-on "Y" Bracket "I"68759 Bolt-on "Y" Bracket "J"68762 Bolt-on "Y" Bracket "K"68765 Bolt-on "Y" Bracket "L"68767 Bolt-on "Y" Bracket "M"68769 Bolt-on "Y" Bracket "N"68771 Bolt-on "Y" Bracket "O"68774 Bolt-on "Y" Bracket "P"68777 Bolt-on "Y" Bracket "Q"68780 Bolt-on "Y" Bracket "R"68783 Bolt-on "Y" Bracket "S"68786 Bolt-on "Y" Bracket "T"68791 Bolt-on "Y" Bracket "U"Other Other Vehicle Information Make (required) Model (required) Year (required) Air BagKnee Bolster Air Bag Steering WheelPower Tilt/Telescope Steering Wheel BrakePower Brakes Dealer Information I of certify that all items on "Final check-out" (located in the back of dealer manual) have been completed and checked. Customer has been given complete instructions on how to operate hand controls. Installation Information Ease of InstallationEasyModerately EasyModerately DifficultDifficult Comments Comments Please leave this field empty.
