Langley Chrysler

Ready to purchase/lease a Daimler Chrysler product.
Aware of the vehicle package and options required.
Qualifies for financing if required.
All family members and or spouses agree on the purchase.
Wish's to purchase at the guaranteed best possible price.
Would like to view the factory to dealer invoice.
Prepared to secure order with deposit via credit card or cheque.
Ready to take delivery in 72 hours.

If you meet the above criteria,
please fill out the form below and our Direct Quote Purchase representative
will be in touch shortly to schedule an appointment

Information Request Form

CONTACT INFORMATION

Name* :
(first name, last name)

Address: (optional)

City* :

Province* :

Postal Code* :

Phone Number* :

( )

Fax Number :

( )

Work Phone Number:

( )

Best time to contact:

E-mail:

Preferred Method of Contact:

Phone

Fax

Comments:

VEHICLE INFORMATION
Vehicle Year* :
Make* :
Model* :


Transmission* :	Automatic Manual
Additional Vehicle Information:

APPOINTMENT INFORMATION
Appointment Time :	am pm
	Year: Month: Date:

Comments:

* Fields marked with an asterisk are required. You cannot submit this form until these blanks are filled.