Contact Information
*First Name:
*Last Name:
*Address:
*City:
*State Issued:	Select 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:	Select One: 2 Door 4 Door Hatchback
Trim Level (if known):
Interior Color:
Exterior Color:
Cylinders:
Liters:
Mileage:
VIN:
Transmission:	Select One: Automatic Manual
Lien Holder:
Estimated Payoff:
Vehicle Options
AM/FM Radio:	Select One: Yes No
Cassette:	Select One: Yes No
CD:	Select One: Yes No
CD Changer:	Select One: No In Dash External
Power Windows:	Select One: Yes No
Power Locks:	Select One: Yes No
A/C:	Select One: Yes No
Rear A/C:	Select One: Yes No
ABS:	Select One: Yes No
Cruise Control:	Select One: Yes No
Tilt Control:	Select One: Yes No
Roof Rack:	Select One: Yes No
Sunroof:	Select One: No Sliding Pop-up
Alloy Wheels:	Select One: Yes No
Drive Train:	Select One: 4WD AWD FWD RWD
Tow Package:	Select One: Yes No
Dual Air Bags:	Select One: Yes No
Side Air Bags:	Select One: Yes No
Power Seat(s):	Select One: No Driver Pass Both
Leather Seating:	Select 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)	Select One: 1 2 3 4 5 6 7 8 9 10
Tires (50% tread wear - replacement)	Select One: 1 2 3 4 5 6 7 8 9 10
Upholstery (Tears, burns, stains)	Select One: 1 2 3 4 5 6 7 8 9 10
Glass (Fractures, spiders, chips)	Select One: 1 2 3 4 5 6 7 8 9 10
Clutch (Clutch skipping)	Select One: 1 2 3 4 5 6 7 8 9 10 n/a
Brakes (Squeaky, noisy)	Select One: 1 2 3 4 5 6 7 8 9 10
Collision History
* Has your vehicle ever been involved in a collision?	Select One: yes no
If yes, was a Body Shop estimate of repairs written?	Select One: n/a yes no
* Were Body Shop repairs performed?	Select One: n/a yes no
* Was the vehicle repaired to your complete satisfaction?	Select One: n/a yes no
Exterior Condition
* Are any of the painted surfaces scratched, rusted, or faded?	Select One: yes no
* Are there any dents and dings?	Select One: yes no
* Have any of the painted surfaces been repainted or touched up?	Select One: yes no
* Does any of the glass have fractures, spiders, or chips?	Select One: yes no
Interior Condition
* Does the upholstery have tears, burns, or stains?	Select One: yes no
* Does the stereo system or any of its components need repairs?	Select One: yes no
* Do all of the gauges and dash functions work?	Select One: yes no
Mechanical Condition
* Does the engine need any repairs?	Select One: yes no
* Does the transmission need any repairs?	Select One: yes no
* Is the clutch slipping or need any repairs?	Select One: n/a yes no
* Are the brakes squeaking or in need of repair?	Select One: yes no
* Has the transmission or engine ever been replaced?	Select One: yes no
Questionaire
Has the vehicle ever been a taxi, rental car, or police car?	Select One: yes no
Has the vehicle ever been in water deeper than the midpoint of the tires?	Select One: yes no
Has the vehicle ever been declared a "Flood" vehicle?	Select One: yes no
Is the vehicle's frame in need of repair?	Select One: yes no
Has your vehicle's frame ever been repaired?	Select One: yes no
Has the vehicle ever had a salvage title?	Select One: yes no
Is this a "lemon law buyback" vehicle?	Select One: yes no
* Has the vehicle ever been declared a total loss?	Select One: yes no
Is the vehicle air bag in working order?	Select One: yes no
Has the vehicle air bag ever been deployed?	Select One: yes no
Do you have any of the service records for this vehicle?	Select One: yes no
Do you have records for any oil change within the last 5000 miles?	Select One: yes no
Is the catalytic converter attached and working properly?	Select One: yes no
Are the inspection stickers current?	Select One: yes no
Has the spare tire ever been used?	Select One: yes no
Do any of the tires need to be replaced?	Select One: yes no
Is the pollution control equipment attached and working properly?	Select One: yes no
Is there anything else we should know about this vehicle?