Vehicle Request Form

Name *

First

Last

Date of Birth *

Phone *

Phone (Alternate)

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Annual Household Income

Number of children within household? *

Birthday [ Child #1 ] *

Birthday [ Child #2 ] *

Birthday [ Child #3 ] *

Birthday [ Child #4 ] *

Member of our previous FCC website? *

Yes
No

Can you drive a manual shift vehicle? *

Yes
No

Are you currently employed? *

Yes
No

Are you a Military Veteran? *

Yes
No

Tell us your military story

Do you have a caseworker? *

Yes
No

Caseworker Name *

First

Last

Caseworker Phone *

Caseworker Phone (Alternate)

Tell us your story

Social Media Platforms?

Facebook
Instagram
Tiktok
X

Facebook

Instagram

Tiktok

X

You may receive a vehicle if your story is truly inspirational and compelling, but we must strongly emphasize that your application’s success will be greatly enhanced by promoting our charity on all social media venues on a regular basis. Example: Donate a vehicle nationwide, in any condition, running or not, to The Original 1-800-Charity Cars. www.800charitycars.org