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Contact Information
First Name:
Last Name:
Address:
City:
State
Zip:
(Area Code) Daytime Phone:
EMail:
Vehicle Information
Year:
Make:
Model
Mileage:
Transmission
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Automatic
Manual
Cylinders
Exterior Color
Interior Color
Trim Level (if known)
Drive Train
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4WD
AWD
FWD
RWD
Doors
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2 Door
4 Door
Hatchback
Truck Cab Size (if applicable)
choose one:
regular cab
extened cab
crew cab
Estimated Payoff
Trade VIN for Carfax
Vehicle Options
Power Windows
choose one:
Yes
No
Power Locks
choose one:
Yes
No
Cruise Control
choose one:
Yes
No
CD
choose one:
Yes
No
CD Changer
choose one:
No
In Dash
External
Power Seat(s)
choose one:
No
Driver
Pass
Both
A/C
choose one:
Yes
No
Rear A/C
choose one:
Yes
No
ABS
choose one:
Yes
No
Leather Seating
choose one:
Yes
No
Sunroof
choose one:
No
Sliding
Pop-up
Alloy Wheels
choose one:
Yes
No
Tow Package
choose one:
Yes
No
Dual Air Bags
choose one:
Yes
No
Side Air Bags
choose one:
Yes
No
Other Options You Wish to Specify:
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
Upholstery (Tears, burns, stains)
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
Glass (Fractures, spiders, chips)
choose one:
1
2
3
4
5
6
7
8
9
10
Brakes (Squeaky, noisy)
choose one:
1
2
3
4
5
6
7
8
9
10
Drive Train (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
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
Have any of the painted surfaces been repainted or touched up?
choose one:
yes
no
Are there any dents and dings?
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
Has the transmission or engine ever been replaced?
choose one:
yes
no
Is the clutch slipping or need any repairs?
choose one:
n/a
yes
no
Questionnaire
Has the vehicle ever had a salvage title?
choose one:
yes
no
Has the vehicle ever been declared a total loss?
choose one:
yes
no
Has the vehicle ever been declared a "Flood" vehicle?
choose one:
yes
no
Do you have any of the service records for this 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
Is the vehicle air bag in working order?
choose one:
yes
no
Has the vehicle air bag ever been deployed?
choose one:
yes
no
Is there anything else we should know about this vehicle?