* Submitter's Name:

* Submitter's Email Address:

* I would like the proceeds of the sale of my vehicle to benefit:

Name as it appears on title:

Last Name:

First Name:

Last Name:

First Name:

Company Name:

Current Address:

Cross Street:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Is the 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.)

Current Address:

City:

State:

Zip:

Contact Person:

Contact Phone:

Vehicle Information

Year:

Make:

VIN:

Model:

# Doors:

Mileage:

Color:

Does your car or vehicle run:

Yes

No

To maximize the value from the sale of your 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?

How do you rate the tires?

Are the tires inflated?

Does the vehicle have a battery?

Is vehicle accessible to tow truck and not parked in garage or grassy area?

Title Number:

Title State:

Title Control Number:

Is there or has there ever been a lien on the 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 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.

* Indicates Response Required