Name (entirely optional):

Address (entirely optional):

State/Province of Residence:

Country of Residence:

Cyber Name (Any will do.):

Enter a 4-digit update code:

E-mail address:

Has your e-mail address changed since the last submission?

        Yes    No

Date:

About you:

Age:

Sex: Male  Female

About your vehicle:

Year:

Manufacturer:

Model:

Current mileage on odometer: Note that 1 km = .621373 miles.

If the number of miles claimed for the vehicle exceed the current mileage on the odometer, please state the number of miles claimed for the vehicle: Note that 1 km = .621373 miles.

If a claim of mileage is made that exceeds the miles on the odometer, please explain the variance:

Note: If you claim more miles on your vehicle than there are on the odometer, you must have the service department(s) forward verifying service histories to J. Bleeker, 56538-0457, U.S.A.

If it has been necessary to add oil between oil changes and this was or is due to oil consumption by the engine, at what mileage did engine oil consumption commence:

miles

Has there been any change in the status of or assessment regarding your engine, transmission, or air conditioner, since the last submission?

 Yes    No

If so, what is that change of status or assessment?

Your current estimate of the life expectancy of your vehicle (from first sale by dealership to original owner):

miles

years

Any additional comments: