Submitter's Name: *

Submitter's Email Address: *

I would like the proceeds of the sale of my car or Vehicle to benefit (States: AK - MS): 🛈

I would like the proceeds of the sale of my car or Vehicle to benefit (States: NC - WY) : 🛈

Name as it appears on title:

First Name:

Last Name:

First Name:

Last Name:

Company Name (if donating a Company Vehicle):

Current Address:

Cross Street:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Is the car or vehicle located at the above address:

If not, indicate car or vehicle location for free towing or pickup. Location Name (i.e. private residence, Smith's Repair Shop, etc.)

Alternate Pickup Address:

Alternate Pickup City:

Alt Pickup State:

Alternate Pickup Zip Code:

Contact Person:

Contact Phone:

Car or Vehicle Information

Year:

Make:

Model:

VIN:

# Doors:

Mileage:

Color:

Does your car or vehicle run:

Yes

No

To maximize the value from the sale of your car or vehicle, could you describe:

Condition of Interior:

Condition of Exterior:

Mechanical Condition (please elaborate):

Help prepare us to tow your car or vehicle:

Do you have keys?

Title Number:

Title State:

Title Control Number:

Is there or has there ever been a lien on the car or vehicle?

On the front of the title, if there is a financial institution mentioned, you will be required to have a lien release.

When your car or vehicle is picked up by our towing company,
where would you like us to leave the receipt?
(Example: mailbox, under door, mail to me)

Have you heard of The Arc?

How were you referred to The Arc?

We welcome your comments in the space below.