Request For Arbitration By The Florida New Motor Vehicle Arbitration Board Page 2
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8FOR OFFICE USE ONLY
OFFICE OF THE
Indicate Date:
Filed
_____________
ATTORNEY GENERAL
Rejected
_____________
Request for Arbitration by the
Withdrawn
_____________
Approved
_____________
Florida New Motor Vehicle
Case #
______________
Arbitration Board
I DO NOT WISH TO RECEIVE SOLICITATION MATERIALS FROM ATTORNEYS
I. CONSUMER INFORMATION
1. Purchaser/Lessee Name(s):
2. Street Address:
City:
State:
Zip Code:
Mailing Address (if different):
City:
State:
Zip Code:
3. Home Phone: (
)
Best Time to Call:
Work Phone: (
)
For Whom?
Cell Phone: (
)
For Whom?
Fax: (
)
E-Mail:
Attorney Information (complete only if you are represented by an attorney):
Name:
Mailing Address:
City:
State:
Zip Code:
Telephone: (
)
Fax: (
)
E-Mail:
II. SELLING DEALER, FINANCING, AND LEASING INFORMATION
4. Dealer Name:
Address:
City:
State:
Zip Code:
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