Apply test - Low Income Auto Repair

Name

First

Last

Email

Phone

Residence address

Address Line 1

Address Line 2

City

State

Zip Code

Number of dependents

Spouse, Children, Step Children, Adopted

Are you currently on any state assistance?

Yes
No

Are you currently employed? If so please list your employers contact information

Your monthly household income

Please list Vehicle Insurance With: Full Coverage / PLPD / None

Which vehicle listed is your main vehicle: (vehicle that takes you to work)

Please tell us why you need to apply for the Low Income Auto Repair Program

a is Program

Your full date of birth (Month/Day/Year)

If a vehicle is not running, do you have a way transport it to a qualified Low Income Auto Repair facility?

Yes
No

Please List the Make/Model/Year/Engine Size of the vehicle you wish to enroll in the program

Make/Model/Year/Engine Size

What is the License plate state and number of the vehicle you wish to enroll in the program?

Please specify: Own/Lease/Payments

Are the vehicles you are applying to be enrolled, in good running condition? If not, please explain what is wrong with them

This program is currently ONLY offered in MICHIGAN, please check the box to confirm you understand:

I understand

How did you find out about our program? If you found us on a website please list which site:

To confirm that you agree the information given in this form is true, complete and accurate, please text box below. that you confirm

I confirm

I understand that I must be pre-approved for each repair that is approved for a discount by the Low Income Auto Repair Application process. Additionally, I understand that any future repairs that have not been approved will be charged at the repair shop's current rates. Please check the box below, if you understand and agree with this statement.

I understand

I understand that Low Income Auto Repair has received your application and someone from the call center will contact you to start your review and be matched with the repair facility under low income system. Please check the box below that you have read this statement and understand.

I understand