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Personnal information :
Name
Adress
City
Phone
Email


Model :
Marque :
Model :
Model year :
Complaint :
In service date (year/month) :
Production date (year/month) :  
serial number (VIN) :
Vehicle owership :
Original owner :
Real mileage :


Mileage at the time of repair :
Mileage :
Repair date (year/month) :
Cost covered by :
If owner or lesse paid, how much did the repairs cost? :  
Did the problem reoccur