CANADIAN WARRANTY CORPORATION
Canadian Warranty Corporation
P O BOX 18379 STN BRM B
TORONTO ON   M7Y 3J1
      
       Please complete this form and mail to the above address.
I HAVE ENCLOSED MY CHEQUE, MONEY ORDER, OR CREDIT CARD INFORMATION FOR:
 (NOTE: RATES APPLY TO MOST VEHICLES) 1 MONTH 3 MONTHS
(Save 5%)		 6 MONTHS
(Save 10%)		 12 MONTHS
(Save 15%)
 POWERTRAIN WARRANTY  $30.14  $81.50  $153.75  $269.80
 EXPANDED WARRANTY  $43.18  $116.80  $220.32  $389.75
         
       

FIRST
NAME
LAST NAME
ADDRESS
CITY
PROVINCE
POSTAL CODE
EMAIL
CUSTOMER NUMBER

PAYMENT METHOD:   CHEQUE
  MONEY ORDER
  VISA/MASTERCARD           CARD NO.
           EXP DATE

MY HOME PHONE NUMBER IS  (        ) ________________ WORK # (        ) ________________CURRENT KILOMETERS ___________
IS TOTAL KILOMETERS OVER 200,000 KM?  YES (IF YES, DO NOT APPLY)  NO
IS VEHICLE USED FOR COMMERCIAL USE?  YES (IF YES, DO NOT APPLY)  NO

VEHICLE YEAR
MAKE
MODEL

EMPLOYER
POSITION
KILOMETERS DRIVEN EACH YEAR
(IF SELF EMPLOYED, STATE TYPE OF SELF EMPLOYMENT) (IF RETIRED, STATE TYPE OF EMPLOYMENT RETIRED FROM)

I UNDERSTAND THE CONTRACT IS NOT IN FORCE UNTIL 21 DAYS AFTER THIS APPLICATION HAS BEEN ACCEPTED AND THE CONTRACT ACTUALLY ISSUED. WARRANTY COVERS APPLICANTS 18 YEARS OF AGE AND ABOVE. MISSTATEMENTS IN THE APPLICATION MAY VOID COVERAGE. I ATTEST ALL INFORMATION IS TRUE AND CORRECT. COVERS MECHANICAL FAILURES THAT OCCUR AFTER THE EFFECTIVE DATE OF THE CONTRACT. I AGREE RENEWALS WILL BE AUTOMATICALLY CHARGED TO MY CREDIT CARD.

SIGNATURE ______________________________________________________________________ DATE: _________________________

                                                                                                                                                                         13004ECUCW

© Copyright 2003 Canadian Warranty Corporation