Statement to Vehicle Owner
This is a FREE limited warranty. No one may charge you for it. It covers fifteen (15) engine parts lubricated by motor oil against lubrication caused failure. It does not extend the vehicle manufacturer's limited warranty. It contains certain conditions, exclusions and service requirements. Individuals, professional associations, or corporations that own or lease vehicles who are primarily obligated for their service and repairs performed at a retail service center may qualify for our program. Those vehicles that are used in commercial, agricultural / farming or competitive racing conditions do not qualify for our warranty.

You must follow the program outlined on the previous page and contained in your limited warranty package to comply with the program. When you receive your limited warranty package, please read it carefully to understand your rights. Save all your receipts for oil changes and engine maintenance.

All fields must be completed.

Personal Information

First Name  Last Name  Name Vehicle Is Registered Under (if different) Address  City  State/Province Postal Code  ---United States--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ---Canada--- Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territory Nova Scotia Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Vehicle Information

Year   Make & Model   VIN   Odometer Reading   Date of Purchase/Lease (mm/dd/yyyy)   Is the vehicle covered by an extended service contract?   YesNo Do you change you own oil?   YesNo

Retailer Information

Retailer Name   Phone   Street Address   City   State/Province Postal Code  ---United States--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ---Canada--- Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territory Nova Scotia Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

By submitting this on-line application, I certify that I have read the above statement and understand it. No other representations about the Quaker State Lubrication Limited Warranty have been made to me. I certify that all the information about my vehicle contained in this application is true.

Quaker State Warranty Headquarters
P.O. Box 5167
Buffalo, New York 14240-5167
1-800-677-6457