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Indicates required field
Name
*
First
Last
Phone Number
*
Email
*
Insurance Company
*
Insurance Policy #
*
Agent Name
*
Insurance Company Ph #
*
Vehicle Year
*
Vehicle Make/Model
*
Vehicle Vin#
*
Vehicle Mileage(must be exact)
*
Availability(next 2 weeks) to drop car at shop
*
Describe current problem with vehicle(Be Specific)
*
Any other prior issues you've noticed with vehicle?
*
Other Comments
*
Submit
extendedCARe Application
*
Indicates required field
Name
*
First
Last
Phone Number
*
Email
*
Did You Graduate Our afterCARe Program?
*
No
Yes
Do You Have Any Outstanding Debt with C4H(If so then how much)?
*
Are You Still Involved With Your Referring Organization(in a current program or having regular conversations)?
*
Are You Currently Employed?
*
How Much Do You Currently Make?
*
$10-$11 per hour
$12-$13 per hour
$14-$15 per hour
$16-$17 per hour
$18-$19 per hour
$20+ or more per hour
Other Sources of Income? How Much?
*
Are You Receiving Government Assistance?
*
No
Yes
Type and amount of Government Assistance
*
Do You Still Have Original C4H Vehicle?
*
Vehicle Mileage(Exact)
*
Current Condition of Your Vehicle?
*
Great
Average
Poor
Is Vehicle Maintenance Current?
*
Yes
No
If No Then What's Overdue?
*
What's Your Current Work Schedule?
*
Is Your Vehicle Drivable?
*
Reason Applying For extendedCARe(Be specific if you're having car problems)
*
Other Comments
*
Submit
Home
PROGRAMS
CAR DONATION
VEHICLE BUYING PROGRAM
afterCARe
>
Calendars
JumpStart
REFERRAL FORM
DONATE A CAR
TAX ADVANTAGES
IMPACT
TESTIMONIALS
PARTNERS
ABOUT
OUR TEAM
OUR FOUNDERS
FAQs
EVENTS
EVENT CALENDAR
Shufflin Home Fundraiser
CHARIOT RACES
PRIOR EVENTS
>
GALA
MUSCLE CARS EVENT
GOLF
RECIPIENTS
CONTACT
COMMUNICATIONS
PUBLICATIONS
HOPE BLOG
SUBSCRIBE TO OUR E-NEWSLETTER
CARS4SALE