James E. Black Cadillac's GMOutlet

"GM Protection Plan Mail/Fax Application Form"

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Instructions:
1	Fill out this page by typing over the "fill in the blanks":	Call 1-877-472-9550 for help
2	Print this page and sign where requested, then clear form with the RESET button:
3	Mail/Fax this page & your check/credit card information to:	Black Pontiac Cadillac 3929 Admiral Peary Hwy Ebensburg, Pa. 15931 Or Fax to: 1-814-472-4741

**No Information You Enter is Being Sent Over the Internet**

Customer Information: (Check Us Out =====>)

. :Name

*Use if Vehicle Titled in Business Name
:Address
:Address
, :City, State Zip
, , :Home, Work, Fax Phone#'s

:E-Mail

Vehicle Information:

, , : YEAR, MAKE, MODEL

: VEHICLE's ID #
:Original In-Service Date
:Current Odometer

with for

GMPP Information:

GMPP.. "Major Guard" on a Vehicle Class :A to H / 1 to 8, (Class Lookup)

*Surcharge: $225 Business, $225 Snowplow *If Applicable
*Surcharge: $350 Hummer Surcharge
*Surcharge: $2,000 Emergency Vehicle
GMPP.. Months Miles with a Deductible ($0, $50, $100, $200 Available)

Payment Information:

$:GMPP List Price

$:GMPP Your Price

..% :Sales Tax % - (0% For Non-PA Residents) or (6% or 7% for PA Residents)

$:Sales Tax Dollar Total

$:*GMPP Surcharge if Applicable (from above)

$: Processing & Handling Fee (Fee Lookup)

$: Discount Special (if in effect – check expiration dates)

$: GMPP Total Price

..: Credit Card Name

..: Credit Card Number

..: Expires On

..: 3 Digit Security Number from back of Credit Card

Please apply for the selected General Motors Protection Plan and I authorize payment with my attached check/credit card information. I understand that for any reason the plan is changed or not offered on my vehicle (vehicle must be within the 3 year or 36,000 miles original manufacture warranty period) that my check/credit card will be returned/not charged and void this transaction. I understand that this plan is fully administered and funded (once activated by GM - approx. 2 weeks) by General Motors and is good in all 50 states (USA). I agree to all terms, benefits, conditions, and limitations of the plan - "General Motors Protection Plan - Major Guard". A small dealership processing & handling (Fee Lookup) will be added to the "GMPP Total Price". I understand that Non-Pennsylvania residents are "Sales Tax Exempt" because of the "Federal Sales Tax Ban"on Internet sales. Pennsylvania residents must pay the appropriate sales tax rate of 6% or 7% depending on your "Pennsylvania County Residence".

X_____________________________________Purchaser Signature on _________/ _________/ ________

Internal Use:	Name	P&H Fee	$C
On & By	Contract#	New / After	CCApp#

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