Warranty Card

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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)

Brackets
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 Installation
Comments
Comments

Please leave this field empty.

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Mounting Information

Vehicle Information

Dealer Information

Installation Information