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Please complete the request form below. ONLY 1 unit per request.

**All fields are required unless otherwise noted.
DEALER INFO
(Exchange Unit will be shipped to this address)
DEALER NAME:
DEALER ADDRESS:
ADDRESS 2 (optional):
CITY:
STATE:
ZIP:
DEALER CODE:
CONTACT NAME:
PHONE: Format: xxx-xxx-xxxx
FAX: Format: xxx-xxx-xxxx
EMAIL:


REPAIR UNIT AND CUSTOMER INFO
REPAIR ORDER # (R.O.):
CUSTOMER NAME:
DATE OF SERVICE REQUEST:  /  /  
VEHICLE MODEL YEAR / MODEL (optional):
MILEAGE:
WARRANTY START DATE:  /  /  
VIN:
NEW CAR BASIC WARRANTY?
Yes No
UNIT SERIAL NUMBER:
OUT OF WARRANTY (RETAIL) PURCHASE?
Yes No
NOTES / COMMENTS / Smart TECHNICAL SUPPORT REFERENCE #:



**Only 1 item can be requested per form.
WARRANTY ITEM RETAIL ITEM PART NUMBER PART NAME VEHICLE MODEL YEAR REMAN/NEW RETAIL PRICE
  DPX503 2DIN AM/FM CD fortwo 09,10 REMANUFACTURED N/A
  GSK-K046 BEZEL fortwo 09,10 REMANUFACTURED N/A
  GSK-K047 JUMPER HARNESS fortwo 09,10 REMANUFACTURED N/A
  KCA-BT200 BLUETOOTH HANDSFREE fortwo 09,10 REMANUFACTURED N/A
  KTC-HR300 HD RADIO TUNER fortwo 09,10 REMANUFACTURED N/A
  KCA-SR50 SIRIUS INTERFACE fortwo 09,10 REMANUFACTURED N/A
  A70-2085-15 Remote fortwo 09,10 REMANUFACTURED N/A
  DPX503 2DIN AM/FM CD fortwo 09,10 NEW $206.00
  GSK-K046 BEZEL fortwo 09,10 NEW $14.70
  GSK-K047 JUMPER HARNESS fortwo 09,10 NEW $6.50
  KCA-BT200 BLUETOOTH HANDSFREE fortwo 09,10 NEW $105.00
  KTC-HR300 HD RADIO TUNER fortwo 09,10 NEW $83.00
  KCA-SR50 SIRIUS INTERFACE fortwo 09,10 NEW $36.00
  A70-2085-15 Remote fortwo 09,10 NEW $9.48

SHIPPING METHOD PRICE WARRANTY
2nd Day Air $14.50 $0.00
Next Day Air $26.00 $0.00
  
PRICE OF EXCHANGE PART(S) REQUESTED to be calculated
SHIPPING $ 2nd Day Air Next Day Air
TOTAL RETAIL PRICE OF REQUEST to be calculated

NOTES:
  • Warranty does not cover customer abuse or damage.
  • No Trouble Found will result in an evaluation and remanufacture fee.
  • New parts may be ordered for In-Warranty replacement only if the vehicle has not been sold.