Premium Protection Service AgreementPremium Protection Service Agreement • January 12th, 2015
CUSTOMER INFORMATION OWNER'S NAMETest Tester STREET ADDRESS111 Test St. CITY, STATE, ZIP CODELees Summit, MO 64086 TELEPHONE NUMBER(111) 222-3333 ALTERNATE PHONE NUMBER E-MAIL ADDRESStest@test.com VEHICLE INFORMATION VEHICLE IDENTIFICATION NUMBER1FTFX1EF3EFB39729 YEAR2014 MAKEFord MODELF150 AGREEMENT TERM EFFECTIVE DATE01/12/2015 SELECT A TERM□ 1 YEAR □ 2 YEARS □x 3 YEARS □ 4 YEARS □ 5 YEARS SALE TYPE□x RETAIL DELIVERY□ POST RETAIL AGREEMENT PURCHASE PRICE$189.00 DEALER INFORMATION NAME OF SELLING DEALERTEST DSD PROGRAM ADDRESS OF SELLING DEALER250 NE MULBERRY LEES SUMMIT, MO 64086 TELEPHONE NUMBER OF SELLING DEALER DEALER NUMBERD9000 SELLING DEALER SIGNATURE DATE01/12/2015 LIENHOLDER INFORMATION LIENHOLDER LIENHOLDER'S ADDRESS CUSTOMER ACKNOWLEDMENT CUSTOMER SIGNATURE DATE
