fields are required.
Contact Information
State Issued:
choose 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:
Vehicle Information
Interior Color:
Exterior Color:
Vehicle Identification No.:
Lien Holder
Estimated Payoff
Overall Vehicle Condition
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
Tires (50% tread wear - replacement)
choose one:
1
2
3
4
5
6
7
8
9
10
Upholstery (Tears, burns, stains)
choose one:
1
2
3
4
5
6
7
8
9
10
Glass (Fractures, spiders, chips)
choose one:
1
2
3
4
5
6
7
8
9
10
Brakes (Squeaky, noisy)
choose one:
1
2
3
4
5
6
7
8
9
10
Collision History
Has your vehicle ever been involved in a collision?
choose one:
yes
no
choose one:
n/a
yes
no
Exterior Condition
choose one:
yes
no
choose one:
yes
no
Interior Condition
choose one:
yes
no
choose one:
Yes
No
choose one:
yes
no
Mechanical Condition
choose one:
yes
no
choose one:
yes
no
Questionnaire
Has the vehicle ever been a taxi, rental car, or police car?
choose one:
yes
no
Has the vehicle ever been declared a "Flood" vehicle?
choose one:
yes
no
Has the vehicle ever had a salvage title?
choose one:
yes
no
Is the vehicle air bag in working order?
choose one:
yes
no
Has the vehicle air bag ever been deployed?
choose one:
yes
no
Do you have any of the service records for this vehicle?
choose one:
yes
no
Is the catalytic converter attached and working properly?
choose one:
yes
no
Do any of the tires need to be replaced?
choose one:
yes
no
Is there anything else we should know about this vehicle?
BRAINERD/BAXTER, MN
