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G 3 6 2 87 <br /> ]>>>7Y0K0HAMASTANDARD WARRANTY CLAIM ADJUSTMENT NO.� ,�j <br /> CLAIM FORM - <br /> FOKOHIAMA TIRE CORPORATION LE, <br /> MACARTHUR PLACE,SUITE 800• SANTA ANA,CA 92707 COPY <br /> .ONSUMER AFFAIRS(800)722-9888 <br /> COTE: DEALER MUST COMPLETE ALL NON-SHADED AREAS. SHADED AREAS ARE FOR YOKOHAMA USE ONLY. <br /> �- ASSOCIATE DEALER ORnNATIION AAL ACCOUNT NAME CUSTOMER DEALER NAME ME NAME END USER <br /> STREET ADDRESS <br /> STREET ADDRESS STREET ADDRESS <br /> CITY,STATE,ZIP CODE <br /> CITY, S I&E, ZIP CODE CITY,STATE,ZIP CODE <br /> PHONE NUMBER <br /> YOK("'"MA DEALER NUMBER CLAIM DATE NATIONAL ACCOUNT NUMBER(IF A01-16ABLE) E-MAIL ADDRESS <br /> MO. DAY YEAR <br /> 00 <br /> ORIGINAL EQUIPMENT VEHICLE YEAR MAKE MODEL POSITION OF CLAIM TIRE(S) NOTICE TO DEALER <br /> ❑YES ❑NO (Please check and indicate item number) If claim is disallowed, the product will be scrapped <br /> VEHICLE MILEAGE DATE;VEHICLE PURCHASED(IF O.E.) FRONT FRONT unless the box below is checked. <br /> ❑ RETURN FREIGHT COLLECT <br /> VEHICLE IDENTIFICATION NUMBER(IF O.E.) CUSTOMER NOTICE <br /> Read Carefully, Before Signing <br /> COMPLETE FOR MILEAGE CLAIMS ONLY(Attach mileage certificate(s)) I hereby certify that to the best of my knowledge the foregoing statements are correct, <br /> that I am the owner of the product presented for claim and that the product described <br /> ODOMETER AT TIRE REMOVAL was not involved in any accident,personal injury,consequential damage or other loss. <br /> I accept credit in lieu of further claim.I understand that the tire(s), detailed on this <br /> ODOMETER AT TIRE INSTALLATION CAR claim,become the property of Yokohoma Tire Corporation. <br /> TOTAL MILEAGE RECEIVED TRUCK <br /> ` CUSTOMER SIGNATURE DATE <br /> ? .� `` � <br /> 2 �, �° r� 1c• -,lam_ f <br /> 115 <br /> W D U YTC TECHNJ%AL SERV�S'R [LsLWAI)VIL DATE / YTC CORPORATE APPROVAL DATE <br /> M-91-1014 �- DE <br /> E <br />