Good Samaritan Auto Care - Service Request

Thank you for your interest in Good Samaritan Auto Care. Please complete all fields on this form. Someone will contact you soon. We look forward to serving you!

Your name *

Email address *

Phone number *

What is your membership status at Sandhills Community Church? *

Membership is not required to receive service.

Year of Vehicle *

Make of Vehicle (Ford, Toyota, Honda, etc.) *

Model of Vehicle (Edge, Sienna, Pilot, etc.) *

Submodel of Vehicle (LX, SE, etc.) *

VIN - 17 characters (letters & numbers) found on your insurance card or the inside driver's door of your vehicle. *

Please give a brief description of the work you would like completed, or what issue needs to be investigated. *

Accept Terms: You will be provided a Service Recipient Waiver. Signature will be required before any work can be performed on your vehicle. *

Service Agreement: Charges will include reimbursement for all discounted parts and supplies used for your vehicle, and a minimal shop fee. Labor is always provided for FREE! Additional donations above and beyond direct fees are tax-deductible and will be used to help offset operational expenses.

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