Candidate Referral Form

Candidate Information

Name

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Caseworker’s Name:

Name of Non-Profit:

Email Address

Phone

Candidate currently owns a vehicle or has a vehicle in the immediate family?YesNo

If yes, please explain the situation:

Has a Valid Driver’s License:YesNo

Has funds for Insurance, Title and Tags?YesNo

Number of people in family:

Number of child seats:

Ages of children:

Can drive Manual Transmission?YesNo

Specific Needs:

Please do not fill in this field.

Get in Touch

524 N. Royal Avenue, Box 1
Front Royal, VA 22630

(540) 635-2455 x 101

CARS CHANGING LIVES works directly with local non-profits to give donated vehicles to someone in need.