Wheelchair Van Trade Evaluation Form

Name:
Address:
City:
State: Zip:
Home Phone:
Work Phone:
Email:

VEHICLE INFORMATION
Year:
Make:
Model:
Color:
Tires Match:
Thread Depth:
Transmission:
Engine:
VIN:
Asking Price:
Vehicle Condition:
Poor Excellent
Lienholder:
Outstanding Liens:
Balance Due:
Please list any problems with the vehicle, if any:

FACTORY OPTIONS
Power Moonroof Cassette Towing Package
Rear A/C and Heat CD 6-CD Premium Wheels
DVD Single CD Only Captain's Chairs
Power Windows Leather Seats Quad Seating
Power Door Locks Driver Power Seat Other:
Keyless Entry Passenger Power Seat
Premium Sound Onboard Navigation Other:
Cruise Control Privacy Glass
AM/FM Stereo Running Boards Other:

MINIVAN ADAPTIVE EQUIPMENT
Conversion Company:
Braun VMI ElDorado Viewpoint Other:



Wheelchair Tie Downs Power Transfer Seat Other:
Hand Control Low-Effort Brakes
Power Parking Brake Back-Up Brakes Other:
Steering Extension Zero-Effort Steering

FULL-SIZE VAN ADAPTIVE EQUIPMENT
Drop Floor:
Full Passenger Cargo Conversion Company:












Slider Door Steering Extension Zero-Effort Steering
Raised Door Back-Up Steering Wheelchair Lift Model:

Wheelchair Lift Location:

Other:

Other:
Wheelchair Tie Downs Power Transfer Seat
Raised Roof Power Door Opener
Hand Control Low-Effort Brakes
Power Parking Brake Back-Up Brakes

 

 

Estimated trade-in value of vehicle is good for 30 days. Vehicle will be re-evaluated upon turn-in. Because this is an electronic estimate, value of vehicle may change upon visual inspection. Estimated value may change due to service repairs if any are necessary. If vehicle is located outside of our business area, transportation costs may be deducted from vehicle price. Please initial that you understand the limitations to this online vehicle estimate:
Initials: