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Please select the award you are applying for:

250,000 kilometers / 155,000 miles 500,000 kilometers / 312,000 miles 750,000 kilometers / 468,000 miles 1,000,000 kilometers / 625,000 miles 1,000,000 miles

High Mileage Award Application


Thank you! Your loyalty and support of Mercedes-Benz is highly appreciated. In order to receive your commemorative award and radiator emblem complete the entire form, have it signed by your dealer representative and return it to the address below. Please allow 4 weeks to process your application. Unfortunately, we are not able to ship to a P.O. Box. U.S. residents only. PLEASE PRINT
OWNER'S NAME ADDRESS CITY PHONE DEALER NAME STATE ZIP E-MAIL ADDRESS SIGNATURE DATE

ADDRESS CITY STATE ZIP

DEALER REPRESENTATIVE SIGNATURE PRINT NAME

VEHICLE INFORMATION
MODEL NAME ODOMETER ADDRESS MILEAGE CITY YOU RECEIVED AN AWARD FOR THIS VEHICLE BEFORE? STATE HAVE YEAR SERIAL NUMBER DATE MILEAGE PERSONALLY DRIVEN (IF NOT ORIGINAL OWNER) ZIP IF YES, WHICH LEVEL AWARD? SIGNATURE

Please return this form to: Mercedes-Benz USA, LLC Consumer Assistance Center Attn: High Mileage Awards 3 Mercedes Drive Montvale, N.J. 07645 Please retain a copy for your records

CCM-01-2008