Today's Date
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MM
DD
YYYY
Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
What is your current marital status?
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Single
Married
Divorced
Separated
Widowed
Cohabitating
Spouse's Name
First Name
Last Name
Supervisor's Work Phone
Supervisor Name
Your Employer
Average hours worked per week
What is your hourly pay rate?
Supplemental Security Income
*
Social Security Disability Income
*
Child Support
*
SNAP
TANF
*
Are you a widow?
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Yes
No
Are you a military veteran?
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Yes
No
Model
*
Year
*
Vin Number or License Plate Number
*
Mileage
*
Are your loan payments up to date?
Yes
No
If not, Please explain why
Please list your vehicle's symptoms. Please DO NOT diagnosis the vehicle, ONLY describe the vehicle's symptoms
Please list the names, ages, and relation of anyone over 17 living in the home
Please list the names, ages, and relation of anyone under 17 living in the home
Reference Number One
*
(Full Name, Phone Number and Relationship)
Please list on separate lines.
Reference Number Two
*
(Full Name, Address, Phone Number and Relationship)
Please list on separate lines.
Why do you feel you should be approved for our services? (Explain how your situation may potentially be more urgent than others requesting assistance.)
*
Tell us how being approved for a low cost vehicle will impact you and your family situation.
Do you attend church? If so, where?
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What attempts have you made to get help for these repairs thus far?
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Have you received assistance through Higher Power Garage before now?
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Yes
No
Are you prepared to attend any and all training and/or courses, if required?
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Yes
No
Are you prepared to pay for the cost of the needed repair parts?
Yes
No
How did you hear about us?
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I understand that Higher Power Garage is a non-profit organization, and therefore relies on the generosity of volunteers and donations.
I understand that the work done by Higher Power Garage is not under warranty, though parts put on my vehicle may be warrantied through the manufacturer.
I understand that there is no cost for labor but I am responsible to pay for the full cost of parts prior to repair.
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I understand that I may not have use of my vehicle for as long as it takes to complete the repairs and that a 'loaner' vehicle is not provided. *
*
I certify that I am the legal owner of this vehicle and I hereby release all volunteers, employees, and the Higher Power Garage from any and all liability in the repairs of my vehicle.
*
I understand that my signature is legally binding and I will be held to the information agreed upon within the application.
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By typing your name in the box below. It will serve as your legally binding signature.
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First Name
Last Name
