Eagle Parts & Products LIBERTY 624 mini User Manual

Page 29

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: __________

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