Personal Information For Pickup

First and Last Name:   

Address: 

City:   State:   Zip: 

Email:

Telephone: Alternate Telephone: Fax:

Earliest Date Vehicle Available To Pickup: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2010 2011

Personal Information For Delivery

First and Last Name:   

Email Address:

Address: 

City:   State:   Zip: 

Telephone:   Alternate Telephone: 

Vehicle Information

City and State of Destination:  

Vehicle Year:    Make and Model:

Vehicle Color:  

Vehicle Identification Number (Vin):

Type of Vehicle:  - - Select One - - Small SUV Midsize Suv Full Size Suv Car Pick-up Truck Regular or Extended Cab Pickup Dualie Quad Cab Pickup Other Truck Van Convertible RV Motorcycle Mini-Van Boat Other

Is Vehicle Operational?  Yes No

Is This Vehicle a Purchase? Yes No

If You Just Purchased This Vehicle, Have You Personally Inspected It? Yes No

Vehicle License Plate Number: 

State: License State Alaska Alabama Arkansas Arizona British Columbia California Colorado Connecticut Dist. of Col. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Ontario Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

Transportation Payment

Total Transportation Price As Quoted:

Total Deposit As Quoted:

 Are You Paying By Credit Card   Yes -   Or Check  Yes -

If Paying By Credit Card, Please Complete Following Fields:

Are You Paying Total Quoted Price Yes - Or Quoted Deposit Yes -

If You Are Paying Other Than Quote Or Quoted Deposit, State Amount:

If Paying By Check, Please Complete Following Fields:

Customer: Name of Person Legally Able to Enter Into Contract:

Email Address: 

Term and Conditions of This Agreement

By checking this box, I certify that I have opened the Terms and Conditions link and carefully read, understand and agree to abide by the terms and conditions agreement that I will be entering into with EZ AutoShippers upon acceptance of said terms and conditions. Checking this box will serve as my E-signature in lieu of my written signature.