Customer Information


Vehicle Information

  

Certification




Instructions:


1. Please completely fill out, sign, and date this form.
Provide the following documents, which are required to process your request.
(Please mark out all personal account numbers on statements for your privacy.)
  • Copy of REPAIR ORDER(S)
  • PROOF OF PAYMENT (any one of the following):
    • Copy of credit card receipt; or
    • Copy of credit card statement; or Copy of cancelled check; or
    • Copy of checking account statement
  • PROOF OF OWNERSHIP (any of the following) :
    • Insurance Card with Name, Address, and VIN; or
    • Copy of Title or Certificate of Title or
    • Bill of Sale or
    • Vehicle Registration or
    • Verification from Company owned vehicle person is Authorized Drive

3. Mail fax or email the completed form and all required documents to the following:
Nissan Consumer Affairs FAX: (615) 267-7771
PO Box 685003 Phone: (800) 647-7261
Franklin, TN 37068-5003 Email: nissanassist@nissan-usa.com