Contact Information
First Name:
Last Name:
Address:
City:
State Issued:
choose one: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia
Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
(Area Code) Daytime Phone:
EMail:
Vehicle Information
Year:
Make:
Model
Doors
choose
one: 2 Door 4 Door Hatchback
Trim Level (if known)
Interior Color
Exterior Color
Cylinders
Liters
Mileage:
Vehicle Identification No.:
Transmission
choose one: Automatic Manual
Lien Holder
Estimated Payoff
Vehicle Options
AM/FM Radio
choose one: Yes
No
Cassette
choose
one: Yes No
CD
choose
one: Yes No
CD Changer
choose one: No
In Dash External
Power Windows
choose one: Yes
No
Power Locks
choose one: Yes
No
A/C
choose
one: Yes No
Rear A/C
choose
one: Yes No
ABS
choose
one: Yes No
Cruise Control
choose one: Yes
No
Tilt Control
choose one: Yes
No
Roof Rack
choose
one: Yes No
Sunroof
choose
one: No Sliding Pop-up
Alloy Wheels
choose one: Yes
No
Drive Train
choose one: 4WD
AWD FWD RWD
Tow Package
choose one: Yes
No
Dual Air Bags
choose one: Yes
No
Side Air Bags
choose one: Yes
No
Power Seat(s)
choose one: No
Driver Pass Both
Leather Seating
choose
one: Yes No
Overall Vehicle Condition
Rate the
condition of the following: 1 being Poor, 10 being Excellent.
Metal/Paint (Scratches, dings,
dents, rust, fading)
choose one: 1
2 3
4 5
6 7
8 9
10
Tires (50% tread wear -
replacement)
choose one: 1
2 3
4 5
6 7
8 9
10
Upholstery (Tears, burns, stains)
choose one: 1
2 3
4 5
6 7
8 9
10
Glass (Fractures, spiders, chips)
choose one: 1
2 3
4 5
6 7
8 9
10
Clutch (Clutch slipping)
choose one: 1
2 3
4 5
6 7
8 9
10 n/a
Brakes (Squeaky, noisy)
choose one: 1
2 3
4 5
6 7
8 9
10
Collision History
Has your vehicle ever been
involved in a collision?
choose one: yes
no
If yes, was a Body Shop estimate
of repairs written?
choose one: n/a
yes no
Were Body Shop repairs performed?
choose one: n/a yes
no
Was the vehicle repaired to your
complete satisfaction?
choose one: n/a yes
no
Exterior Condition
Are any of the painted surfaces
scratched, rusted, or faded?
choose one: yes no
Are there any dents and dings?
choose one: yes no
Have any of the painted surfaces
been repainted or touched up?
choose one: yes no
Does any of the glass have
fractures, spiders, or chips?
choose one: yes no
Interior Condition
Does the upholstery have tears,
burns, or stains?
choose one: yes no
Does the stereo system or any of
its components need repairs?
choose one: yes
no
Do all of the gauges and dash
functions work?
choose one: yes
no
Mechanical Condition
Does the engine need any repairs?
choose one: yes no
Does the transmission need any
repairs?
choose one: yes no
Is the clutch slipping or need any
repairs?
choose one: n/a yes
no
Are the brakes squeaking or in
need of repair?
choose one: yes no
Has the transmission or engine
ever been replaced?
choose one: yes no
Questionnaire
Has the vehicle ever been a taxi,
rental car, or police car?
choose one: yes no
Has the vehicle ever been in water
deeper than the midpoint of the tires?
choose one: yes
no
Has the vehicle ever been declared
a "Flood" vehicle?
choose one: yes
no
Is the vehicle's frame in need of
repair?
choose one: yes
no
Has your vehicle's frame ever been
repaired?
choose one: yes no
Has the vehicle ever had a salvage
title?
choose one: yes no
Is this a "lemon law buyback"
vehicle
choose one: Yes NO
Has the vehicle ever been declared
a total loss?
choose one: yes no
Is the vehicle air bag in working
order?
choose one: yes no
Has the vehicle air bag ever been
deployed?
choose one: yes no
Do you have any of the service
records for this vehicle?
choose one: yes no
Do you have records for any oil
change within the last 5000 miles?
choose one: yes no
Is the catalytic converter
attached and working properly?
choose one: yes no
Are the inspection stickers
current?
choose one: yes no
Has the spare tire ever been used?
choose one: yes
no
Do any of the tires need to be
replaced?
choose one: yes no
Is the pollution control equipment
attached and working properly?
choose one: yes no
Is there
anything else we should know about this vehicle?
