Warranty & Marketing Registration Application

Select Rewards members agree to provide marketing information including vehicle ownership and warranty registration that may qualify for incentive. Rewards members that receive incentive may be liable for any federal, state or local taxes. Select Rewards members may opt-out at any time by contacting Sharon Rose: 631-544-9000 or srose@dejana.com.

Click HERE if you wish to print the form, fill out by hand and fax to 631.544.3503 to complete the application. If you wish to mail a hard copy of the application, please mail to:

Dejana Truck & Utility Equipment Co.
500 Pulaski Rd.
Kings Park, NY 11754

Step 1 of 2

Cardholder Information:
Name*
Full Legal First Name MI Full Legal Last Name
Legal Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Legal Mailing Address (If Different)
Street Address City State / Province / Region ZIP / Postal Code
Home Phone*
Cell Phone
Email*
Date of Birth*
Social Security or Taxpayer ID*

Warranty & Marketing Registration Application

Step 1 of 2

Cardholder Information:

Dealership Information:

Need more help? Contact a Dejana Sales Rep.