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Mercedes-Benz of Fredericksburg Rewards Pass Enrollment Form

PLEASE FILL OUT THE FOLLOWING INFORMATION WITH RESPECT TO THE VEHICLE TO BE ENROLLED IN THE Mercedes-Benz of Fredericksburg REWARDS PASS POINTS PROGRAM.

AFTER COMPLETING THIS FORM, PRESS Register Me.

*Required Fields are denoted with an "*" asterisk.

Contents

Please provide the following Vehicle Purchase Information:

Did you purchase this vehicle from the Mercedes-Benz of Fredericksburg?

Yes No

Please choose the Dealership Name where you purchased your vehicle:

Please provide the following Contact Information:

First Name   *
Last Name   *
Company Name
Street Address   *
Address (cont.)
City   *
State   *
Zip   *
Work Phone
Home Phone
FAX
E-mail

Please provide the following Vehicle Information for the vehicle you wish to enroll in the Mercedes-Benz of Fredericksburg Rewards Pass Program:

Year   * (YYYY)
Make   *
Model   *
Vehicle Information Number   * (VIN)
       
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