New Client Application

NEW CLIENT APPLICATION FORM

NOTE: First-time clients must complete this new client application before requesting service.

Repair Days are one Saturday a month, and by appointment only.
Repair clinics are held at First Baptist Church of Ponca City between 5th and 6th streets on Oklahoma Ave.

Contact Us

First Name

Last Name

Street Address

City

State

Zip Code

Email Address

Phone Number

Marital Status

Date of Birth

Gender

Disabled?

Veteran?

Race

Household Income

Number in Home?

Home is Owned/Rented

Employment Status

Vehicle Year

Vehicle Make

Vehicle Model

Vehicle Color

VIN

Problem with vehicle?

How did you hear about CCAR?

New Client Application

NEW CLIENT APPLICATION FORM

Contact Us

Contact Info