LIBERTY™ 324, 424, 624, 324 MINI, 624 MINI & 624 RELIANCE
WARRANTY REGISTRATION
(Please type or print)
DATE PURCHASED: __________________________ SERIAL NO.: _______________________
NAME: ____________________________________________________________________________
ADDRESS: _________________________________________________________________________
CITY: ___________________________________ STATE: ____________________ZIP: __________
DEALER NAME: ___________________________________________________________________
ADDRESS: _________________________________________________________________________
CITY: ___________________________________ | STATE: ____________________ZIP: __________ |
OPTIONAL INFORMATION TO ASSIST US IN DEVELOPING FUTURE PRODUCTS | |
AGE: _________ WEIGHT: ____________ | HEIGHT: _________ SEX: ___________ |
PHYSICAL LIMITATIONS – IF ANY: ___________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
FAVORITE ACTIVITIES: _____________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
FAVORITE LIBERTY™ FEATURES: __________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
If you would like us to send information about the LIBERTY™ PERSONAL MOBILITY VEHICLES to someone you think will Benefit from it please fill in the following:
NAME: ____________________________________________________________________________
ADDRESS: _________________________________________________________________________
CITY: ___________________________________ STATE: ____________________ZIP: __________
MAIL TO ADDRESS | FOLD TOP |
ON BACK. | TO HERE, |
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