Please complete all of the required information below: Name * Name of Evaluator Company * Email Address * Phone * Address * Vehicle for Conversion Year * Make * Model Transmission Type * Automatic Manual Which system fits the need of your clients more, Soft Touch Driving or the RediAuto Sport system? * Would your organization consider leasing a converted manual transmission vehicle approximately $400 monthly? * yes no Does the vehicle currently have a manufacture’s hand controls installed? * Yes No If yes, please explain Does your organization work with: * local PT’s VA Hospitals DOR None If so please provide full contact information, and contact names of each institution: Please provide information on the insurance carrier for the vehicle to be converted. Insurance company * Insurance Agent * Does this vehicle belong to: the organization an individual How many miles does the vehicle currently have? What regions or counties do you serve? Are there any other evaluator organizations that you believe there would be an interest in RediAuto Sport’s Free ADED Equipment, if so please provide contact info. RediAuto Sport’s equipment requires professional installation, who is your local installer/mobility dealer(s)?