Contact Information
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| First Name: |
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State Issued: |
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| Last Name: |
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Zip: |
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| Address: |
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(Area Code) Daytime Phone: |
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| City: |
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EMail: |
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Vehicle Information
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| Year: |
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Cylinders: |
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| Make: |
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Liters: |
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| Model: |
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Mileage: |
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| Doors: |
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Vehicle Identification No.: |
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| Trim Level (if known): |
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Transmission: |
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| Interior Color: |
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Lien Holder: |
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| Exterior Color: |
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Estimated Payoff: |
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Vehicle Options
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| AM/FM Radio: |
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Tilt Control: |
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| Cassette: |
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Roof Rack: |
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| CD: |
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Sunroof: |
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| CD Changer: |
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Alloy Wheels: |
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| Power Windows: |
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Drive Train: |
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| Power Locks: |
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Tow Package: |
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| A/C: |
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Dual Air Bags: |
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| Rear A/C: |
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Side Air Bags: |
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| ABS: |
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Power Seat(s): |
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| Cruise Control: |
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Leather Seating: |
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Overall Vehicle Condition
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| Rate the condition of the following: 1 being Poor, 10 being Excellent. |
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| Metal/Paint (Scratches, dings, dents, rust, fading) |
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Glass (Fractures, spiders, chips) |
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| Tires (50% tread wear - replacement) |
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Clutch (Clutch slipping) |
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| Upholstery (Tears, burns, stains) |
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Brakes (Squeaky, noisy) |
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Collision History
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| Has your vehicle ever been involved in a collision? |
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Were Body Shop repairs performed? |
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| If yes, was a Body Shop estimate of repairs written? |
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Was the vehicle repaired to your complete satisfaction? |
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Exterior Condition
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| Are any of the painted surfaces scratched, rusted, or faded? |
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Have any of the painted surfaces been repainted or touched up? |
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| Are there any dents and dings? |
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Does any of the glass have fractures, spiders, or chips? |
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Interior Condition
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| Does the upholstery have tears, burns, or stains? |
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Do all of the gauges and dash functions work? |
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| Does the stereo system or any of its components need repairs? |
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Mechanical Condition
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| Does the engine need any repairs? |
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Are the brakes squeaking or in need of repair? |
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| Does the transmission need any repairs? |
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Has the transmission or engine ever been replaced? |
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| Is the clutch slipping or need any repairs? |
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Questionnaire
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| Has the vehicle ever been a taxi, rental car, or police car? |
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Is the vehicle air bag in working order? |
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| Has the vehicle ever been in water deeper than the midpoint of the tires? |
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Has the vehicle air bag ever been deployed? |
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| Has the vehicle ever been declared a "Flood" vehicle? |
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Do you have any of the service records for this vehicle? |
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| Is the vehicle's frame in need of repair? |
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Do you have records for any oil change within the last 5000 miles? |
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| Has your vehicle's frame ever been repaired? |
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Is the catalytic converter attached and working properly? |
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| Has the vehicle ever had a salvage title? |
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Are the inspection stickers current? |
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| Is this a "lemon law buyback" vehicle |
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Has the spare tire ever been used? |
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| Has the vehicle ever been declared a total loss? |
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Do any of the tires need to be replaced? |
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Is the pollution control equipment attached and working properly? |
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| Is there anything else we should know about this vehicle?
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