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Call: (713) 942-0808 |  6300 West Loop South Suite 280 Bellaire, Texas 77401

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Contact Information
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Vehicle Information
Year     Make     Model  
Vehicle was: Purchased Leased
Date Purchased     Year  
Current Mileage
This vehicle was purchased/leased:  
  New     Used     Demo
Approx. Mileage at purchase (if vehicle is used)
Type of Warranty:  
 
Repair History
Defects and Nonconformities
In the spaces provided , please list the SYMPTOMS that you have experienced with your vehicle, the number of trips to the dealer for each symptom (whether documented or not), and the appropriate date(s) when the vehicle was inspected and/or repaired for each symptom.
    Symptoms
(Defects & Nonconformities)
      # of Trips
to Dealer
      Dates in Repair
Shop (_/_/_)
1.     1.     1.  
2.     2.     2.  
3.     3.     3.  
4.     4.     4.  
5.     5.     5.  
6.     6.     6.  
Total Number of Repair/Work Orders in your possession:  
Approximate Total number of CALENDAR DAYS vehicle has been out of service and/or in the repair shop:  
 
Can You List 4 Repair Attempts For The Same Complaint?
(if you do not have four identical complaints, just list what you have)
    Date       Problem       Resolution
1.     1.     1.  
2.     2.     2.  
3.     3.     3.  
4.     4.     4.  
 
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