New Vehicle Registration Form

Dynamic Sealant Limited Warranty
Dealership Name*
Dealership Phone #*

Area CodePhone Number
Dealership Contact Email*
Dealership Sales Person*

First NameLast Name
Dealership Address*

Street Address

Street Address Line 2

CityState

Zip Code
Contract Holder Name*

First NameLast Name
Contract Holder Cell Phone #*

Area CodePhone Number
Contract Holder E-mail*
Contract Holder Home Phone #

Area CodePhone Number
Contract Holder Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Vehicle Information
Year*
Make*
Model*
Odometer*
Vin #*
Plan Information
Selected Coverage Type(s)*

Dynamic Sealant Limited WarrantyDynamic Sealant Deluxe Limited Warranty
Add on PermaSafe Vehicle Disinfection and Surface Protection*

Yes, please kill 99.999% of bacteria.No, I'll keep my bacteria, fungi, and mold.
Agreement Purchase Date*

MonthDayYear
Agreement Term*

60 Months
Product Price*
IMPORTANT NOTICE TO THE CUSTOMER

This agreement is not transferable. During the agreement period, we will cover the services described in the What’s Covered section of your contract booklet on an annual basis, provided that you comply with the terms and conditions of your contract booklet.
Contract Holder Signature

Clear
Date

MonthDayYear
Date
DYNAMIC WARRANTY ADMINISTRATION

1-866-696-6543 | 3900 DAVE WARD DRIVE, SUITE 1900 #176, CONWAY, AR 72034
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Dynamic Sealant Limited Warranty