Please Complete this Secure On-Line Appraisal Form
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Required Field
VEHICLE INFORMATION will be sent to Kurt Chase.
First Name:
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Last Name :
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Phone Number:
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Email address:
Year, Make, Model:
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VIN#
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License Plate #:
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Trim Level (ie. LX, SLE, C40, etc...):
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Current Miles:
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Ext. Color:
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Int. Color:
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When selecting from multiple boxes your choices are on the right of the boxes you select.
Exterior Condition:
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excellent
very good
good
fair
poor
Interior Condition:
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excellent
very good
good
fair
poor
Doors:
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2 door
3 door
4 door
other
.....Leather Interior:
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yes
no
Air Condition:
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blows cold
broken
dual
none
Power Seats:
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dirver's seat only
both front seat
no power seats
Transmission:
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automatic
manual
other
Radio:
am/fm
cassette
single cd
multi cd
none
broken
Tires:
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new
very good
good
poor
match
don't match
Wheels:
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alloy
chrome
steel
covers
other
none
Extras:
power windows
power door locks
entertainment center
sunroof
moon roof
t-tops
navigation system
tilt steering wheel
cruise control
side airbags
Trucks:
2wd
4wd
single cab
extra cab
crew cab
bucket seats
bench seats
towing package
Windshield:
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no damage
chipped
cracked
Hail Damage:
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no hail damage
hail damage repaired
hail damage not repaird
Number of Keys:
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1
2
3
4
.....Number of Remotes:
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none
1
2
3
4
Additional Equipment Not Listed Above:
List Damage Not Repaired:
List Damage That Has Been Repaired:
Describe Areas That Have Been Painted:
Bank - Lien Holder
Account #:
Any comments or questions you may have:
I attest that the information I have given here is, to the best of my knowledge, accurate.
Date:
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Signature:
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Security Code
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