Benevolence Car Giveaway

VIEW PICTURES OF PAST GIVEAWAYS

DOWNLOAD THE APPLICATION

FILL OUT AND SUBMIT YOUR BENEVOLENCE APPLICATION BELOW

PERSONAL INFORMATION

First Name

Last Name

Date of Birth

Email Address

Phone Number

Address

City

State

Zip

Driver's License Number

License State

Exp.

OTHER PERSONS LIVING IN HOUSEHOLD

Name

Age

Relationship

Name

Age

Relationship

Name

Age

Relationship

Name

Age

Relationship

Name

Age

Relationship

Name

Age

Relationship

MONTHLY INCOME/EMPLOYMENT INFORMATION

Place of Employment (if applicable)

Type of Employment (if applicable)

Wages

Amount for Self

Amount for Spouse

Household Members Amount

Total Amount

Unemployment

Amount for Self

Amount for Spouse

Household Members Amount

Total Amount

Workers Comp

Amount for Self

Amount for Spouse

Household Members Amount

Total Amount

Pension

Amount for Self

Amount for Spouse

Household Members Amount

Total Amount

Social Security

Amount for Self

Amount for Spouse

Household Members Amount

Total Amount

TANF

Amount for Self

Amount for Spouse

Household Members Amount

Total Amount

Disability

Amount for Self

Amount for Spouse

Household Members Amount

Total Amount

Other

Amount for Self

Amount for Spouse

Household Members Amount

Total Amount

STATEMENT OF NEED

1. Please explain your situation and why you need a car: This should explain what challenges you have faced in your life and any difficulties you are experiencing such as medical, employment, etc.

2. How would a car improve the quality of life for you and your family?

Name of Referring Agency: (if applicable)

Agency Contact Person

Agency Contact Phone Number

I certify that:

I am a resident of the City of the Ben Clymer’s shop giving the car away.
I am willing to share my story with the media.
I am willing to provide any needed verifications to validate my need for this car.
I have and will provide proof of a valid, current California driver’s license.
I have a clean DMV record.
I am able to be insured.
I will sign release forms for media and liability.
The information in this application is true to the best of my knowledge.

I have read and understand the statement above.

VISIT A BEN CLYMER'S LOCATION TODAY!

Conveniently located across southern California, just east of Los Angeles, Ben Clymer's The Body Shop has 5 locations to serve you better. Click a location below to find us or send a message.