Fill out this form before coming in and receive $5.00 off your first purchase.

Customer Information

Name: _____________________________________________________

Address: ___________________________________________________

City: ________________________  State: _______   Zip: ___________

Phone: _____________________

Vehicle Information

Make: ___________________    Mileage:  _______________

Model: __________________     Lic. Plate:  _____________

Year:   ___________________    Color:  _________________

Tire Size:  _____________________________________

                       example:   195/65R15 91T

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