TELL US ABOUT YOURSELF

We do have some "top-level" verifiable qualifications that applicants MUST meet for further consideration. These are:

Resident of Franklin, Delaware, Licking, Fairfield, Pickaway, Madison, Union Counties?
Currently Employed
Valid Driver's license
Insured OR Insurable (able to be insured and can maintain auto insurance coverage)
Current on auto payments or full ownership status

First Name *

Last Name *

Email *

Phone *

Address *

City *

State *

Postal code *

Are you a resident Franklin, Delaware, Licking, Fairfield, Pickaway, Madison, or Union Counties, Ohio? *

Are you currently employed 40-hours per week? (must be verifiable) *

Do you have a valid driver's license? *

Yes

If so, please include your Driver's License number.

Are you current on auto payments, or do you have full ownership of your vehicle? *

Yes

Do You Have Valid Auto Insurance? (Must Be Verifiable) *

YOUR VEHICLE

Vehicle YEAR *

Vehicle MAKE *

Vehicle MODEL *

Is the vehicle drivable or running at all? *

Briefly share your best understanding of the mechanical issue. *

Have you received a repair estimate? *

If you've received an estimate, please include that information here (including the repair shop info)

Was damage the result of an accident? *

If so, please indicate the date of the incident.

Was insurance contacted?

YOUR SITUATION

Here we will ask a few questions about your need, and your situation.

What is the name, phone number, and email of your current employer? *

How long have you worked at your current job? *

Do you have dependents? *

If you have dependents, how many and what ages? *

How are your transportation needs currently being met? *

Please describe your situation, regarding your hardship and/or need. *

Is there anything else you would like to add? If referred by a social/case worker, please include their name and contact information here.