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*Fields marked with an asterisk are mandatory PERSONAL INFORMATION *Name: City: *E-mail: *Telephone: () VEHICLE INFORMATION Make: Model: Kilometers: License plate number: Year: YOUR APPOINTMENT... Date (1st choice):    [Calendar] At what time (1st choice)? Date (2nd choice):    [Calendar] At what time (2nd choice)? Work requested and/or comments: Type the characters you see in the picture:  YES! I want to receive information on future contests, surveys, special promotions and new content from "Centre Hamel Honda".

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Centre Hamel Honda - 332, rue Dubois Saint-Eustache (Québec)  J7P 4W9   Tel.: 450 491-0440   Fax: 450 473-2311

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