Subaru VIP Program Request

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Email*

Please enter your PHS Membership ID

Note: Contributing, Activist, and Advocate members (memberships less than $500) will be eligible to receive these benefits after six (6) months while Champion members or higher (memberships of $500 or more) will be eligible to receive these benefits after thirty (30) days.

Vehicle/Model Preference

Preferred Dealership

Dealer Location (City, State)