Win a $200 Gas Card

Your First Name:


Your Last Name:


Your Gender:  Female   Male

Telephone:


Email:


Address:


City:


Postal Code:


How did you find out about this contest?
-please select- Newsletter Print Ad Website Poster

Do you service your vehicle at Sil's Auto Diagnostic Centre?  Yes       No 


How many vehicles are in your household?    1 2 3 4 5

When was the last time you serviced your vehicle?   0 - 3 months ago 3 - 6 months ago 6 - 12 months ago 12 - 24 months ago

Your Vehicle Details:

Make      Model     Year
Make      Model     Year
Make      Model     Year

What proportion of your total auto repairs and services expenditures do you spend at Sil's Auto Diagnostic Centre?
Less than 10%
10 - 30%
31 - 50%
51 - 70%
71 - 90%
Almost All

What is the total household income?
-please select- Less than $50,000 $50,000 - 74,999 $75,000-99,999 $100,000-149,999 $150,000 $200,000 and Up


Have you had any vehicle breakdowns this year? Y  N

If so, what was the cause? (ie. Dead Battery, Tire Blow Out...)


Do you commute to another City to work? Y   N

Do you carpool to work? Y  N

Do you take driving vacations with your family? Y  N

Please check off the vehicle services below that you have over the last 6 months:

New Tires    Brake Service    Oil Change Service (LOF)  

Aquapel Windshield Treatment   Seasonal Maintenance Service


Do you have a colleague or friend that you would like to refer to this promotion? 
If so, enter their name and email address below:

Name of your colleague or friend:


Contact Email:

Do you have any additional comments to send us?


Thank you for participating.  Click the ’Submit’ button to send in your entry ballot.

Please type in the six letters and/or numbers you see in the box below.