Evaluation Form

Creation of a Protective Shield to Neutralize
Harmful Waves in your Vehicle

Vehicle Evaluation

To Protect Occupants from Harmful Waves

Name:

Surname:

Brand/Model:

Year:

Click on the Circles Corresponding to your Vehicle to Determine the Kit that will Protect You
from Harmful Waves.

Vehicle Type

Gasoline
Hybrid
Electric

Vehicle Category

Compact
Sedan/Family
SUV/Jeep/Minivan
Pickup/Truck

Vehicle Year

Before 2005
From 2005 to 2014
From 2015 to 2021
From 2022 to 2025

Wireless Connections while Driving

Check your percentage of use for each type of connection

Internet (Cell Phone)
0% / NA
1-25%
26-50%
51-75%
76-100%

Bluetooth (Hands-Free Calls)
0% / NA
1-25%
26-50%
51-75%
76-100%

GPS (Cell Phone or Vehicle)
0% / NA
1-25%
26-50%
51-75%
76-100%

Number of Turned-On Cell Phones

Integrated Features

Check Yes or No for each Feature according to your situation

Interior LED Lighting
No
Yes

Blind Spot Detector
No
Yes

Rear Camera Object Detector
No
Yes

Front Object Detector
No
Yes

Tire Pressure Detector
No
Yes

Night Pedestrian Detector
No
Yes

Electronic Dashboard
No
Yes

Features

Check your percentage of use for each Feature

Total Score:



Best Quality



Fast Shipping



Excellium Quality

THE COMPANY

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CONTACT US

Canada

2632 boul. Curé Labelle #101
Prévost, Québec, J0R 1T0

1-888-545-1366
info@clubexcellium.com

PAYMENTS METHODS

The products offered by Alliance Anti-Age Inc. do not in any way replace medical treatment.