Application Form - Clean Fleet Auto Body

Name(Required)

First Last

Email(Required)

Phone(Required)

Address

Street Address Address Line 2 City State ZIP Code

Do you have a current driver's license?(Required)

If yes, please attach a current DMV driving record report with at the bottom.

Yes
No

Driver's License Number

Expiration Date

State

Do you currently have auto insurance?(Required)

Yes
No

Has your driver’s license ever been suspended or revoked?(Required)

Yes
No

Have you had any moving violations or criminal infractions in the past two years?(Required)

Yes
No

Are there any other members of your household with a current valid driver's license?(Required)

Yes
No

Can you drive a manual/stick shift transmission car?(Required)

Yes
No

This event will be covered by the media, are you willing to appear on TV?(Required)

Yes
No

Are you currently employed?(Required)

Yes
No

Please list the name, address and telephone number of your employer/supervisor.

Confirmation(Required)

All interested applicants must send a 1-page narrative explaining why the lack of reliable transportation interferes with your current and future economic status, and how receiving this automobile will assist you in becoming self-sufficient, along with their resume, and current DMV driving record report. These can be dropped off to Clean Fleet Auto Body at 4432 Hearst Street Metairie LA 70001, faxed to 504-888-0507, emailed to davidr@cleanfleetautobody.com, or attached to this form.

All applications are due by October 15, 2021.

Yes, I understand

File Upload

Please upload any relevant documents you have here.

Drop files here or

Accepted file types: jpg, png, pdf, txt, doc, docx, Max. file size: 50 MB, Max. files: 10.

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Benevolence Family Application Form