GM Warranty Administration Program Subscription Form

For assistance with completing this form

> Call: 1.800.852.6298
> Email: customer service

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Yes, sign me up! I understand my dealer account will conveniently be billed $40 a month for as long as I want the program and I can cancel at any time.
1. Contact information (name of individual who is to receive the program)
* First Name:	* Last Name:
Title:	Other:

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2. Company information:
* Company Name: * Dealer Code: Mailing Address: City:
State/Province: * Zip: Email:			* Phone: Phone Extension: Fax:
Shipping Address (if different from mailing): City:
State/Province:			Zip:

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3. Reason for interest in this product:

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* 4. Discounts: If you received a direct mail piece please provide the offer code to apply any applicable discounts.
OC# (Found near phone # or mailing label)
If you didn't receive a direct mail piece (postcard / letter / flyer), how did you know to seek J&L Warranty Pros for help?
		Other: