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Copyright 2004 Northern State Auto, Inc.  210 South Walnut Street    Elmira, New York   14904    607-734-3752        Toll  Free   888-803-8219      Web Design by Marlene Andes
POTENTIAL CUSTOMER
Please make an entry for each field (blank)  if does not apply enter n/a or --.  
LAST
NAME:
FIRST
NAME:
STREET
ADDRESS:
ZIP
CODE:
CITY:
STATE:
HOME PHONE #:
CELL PHONE#:
DRIVER'S
LICENSE#:
STATE
ISSUED:
BEST TIME TO CALL:
WANTED:
YEAR (S)
MAKE(S)
MODEL(S)
MILEAGE
RANGE
SIZE(S)
PRICE RANGE(S)
POWER
LOCKS
AUTOMATIC
TRANSMISSION
TILT STEERNG
WHEEL
CRUISE
CONTROL
EXTENDED
CAB
POWER
STEERING
AIR
CONDITIONING
4x4
STANDARD/MANUAL
SHIFT
EQUIPMENT:
OTHER:
OPTIONS WANTED
SPECIFIC DISLIKES:
SPECIFIC LIKES:
COLORS LIKE
COLORS DISLIKE
YEAR
MODEL
TRADE-IN?
NO
YES
MAKE
MILEAGE
AMOUNT
LIEN HOLDER?
WANT TO BE IN MONTHLY PAYMENT RANGE OF
WANT BY
YES
Are you interested in purchasing an Extended Warranty?
NO
DEALER FLEXIBILITY?
ADDITIONAL INFORMATION
BY CHECKING THIS BOX I AM ACKNOWLEDGING THAT I AM AUTHORIZING NORTHERN STATE AUTO INC TO TRY
LOCATE A VEHICLE FOR POSSIBLE PURCHASE.  I REALIZE THAT BECAUSE THEY ARE LOOKING FOR A
USED/PRE-OWNED VEHICLE THAT I MOST LIKELY WILL NOT BE ABLE TO GET ANY OR ALL OF THE OPTIONS
THAT I HAVE SELECTED.