Benevolence
application
Mike Rose's Auto Body
A-Coat Selected National Benevolence Program
Recipient Application Form
Name:
Date:
Address:
Daytime Phone:
Evening/ Cell Phone:
Driver Information
Do you have a current valid driver's license?
Yes
No
If Yes, please attach a current DMV driving record report with application.
Drivers License Number:
Expiration Date:
 State:
Has your driver's license ever been suspended or revoked?
Yes
 No
Have you had any moving violations or criminal
infractions in the past two years?
Yes
No
Do you currently have auto insurance?
Yes
No
Are there any other members of your household with a
current valid drivers license?
Yes
No
Can you drive a manual/stick shift transmission car?
Yes
 No
This event will be covered by the media, are you willing to
appear on TV?
Yes
No
Employment Information
Are you currently employed?
Yes
No
If yes, please list the name, address and telephone number of your employer/supervisor.
Please write at least a one-page narrative below 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.
We require a copy of your DMV Printout.
Please scan and email to Benevolence Committee
or
Fax to 925-689-1660
Where Quality Counts