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Contact Information
State Issued:
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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:
Vehicle Information
Doors
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2 Door
4 Door
Hatchback
Interior Color
Exterior Color
Liters
Vehicle Identification No.:
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Automatic
Manual
Lien Holder
Estimated Payoff
Vehicle Options
CD Changer
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No
In Dash
External
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Yes
No
Power Locks
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Yes
No
A/C
choose one:
Yes
No
Rear A/C
choose one:
Yes
No
ABS
choose one:
Yes
No
Cruise Control
choose one:
Yes
No
Roof Rack
choose one:
Yes
No
choose one:
No
Sliding
Pop-up
Alloy Wheels
choose one:
Yes
No
Drive Train
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4WD
AWD
FWD
RWD
Dual Air Bags
choose one:
Yes
No
Side Air Bags
choose one:
Yes
No
Power Seat(s)
choose one:
No
Driver
Pass
Both
choose one:
Yes
No
Overall Vehicle Condition
Rate the condition of the following: 1 being Poor, 10 being Excellent.
choose one:
1
2
3
4
5
6
7
8
9
10
choose one:
1
2
3
4
5
6
7
8
9
10
choose one:
1
2
3
4
5
6
7
8
9
10
choose one:
1
2
3
4
5
6
7
8
9
10
Clutch (Clutch slipping)
choose one:
1
2
3
4
5
6
7
8
9
10
n/a
Brakes (Squeaky, noisy)
choose one:
1
2
3
4
5
6
7
8
9
10
Collision History
choose one:
yes
no
choose one:
n/a
yes
no
choose one:
n/a
yes
no
Exterior Condition
choose one:
yes
no
choose one:
yes
no
choose one:
yes
no
choose one:
yes
no
Interior Condition
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yes
no
choose one:
yes
no
Mechanical Condition
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yes
no
choose one:
yes
no
choose one:
n/a
yes
no
choose one:
yes
no
choose one:
yes
no
Questionnaire
Has the vehicle ever been in water deeper than the midpoint of the tires?
choose one:
yes
no
choose one:
yes
no
choose one:
yes
no
Has the vehicle ever had a salvage title?
choose one:
yes
no
Is this a "lemon law buyback" vehicle
choose one:
Yes
NO
choose one:
yes
no
Is the vehicle air bag in working order?
choose one:
yes
no
choose one:
yes
no
Is the catalytic converter attached and working properly?
choose one:
yes
no
Is the pollution control equipment attached and working properly?
choose one:
yes
no
Is there anything else we should know about this vehicle?
