Wounded Wheels

Restoring Heroes and Hot Rods

2400 Hampton Blvd Suite A

Norfolk, VA 23517

(757) 609-0507

Application for Consideration of the2000 Chevrolet Camaro Z28 for the Wounded Wheels program

We are making preparations to give away a Wounded Wheels program vehicle, a 2000 Chevrolet Camaro Z28 (automatic shift), which is excellent condition and should require few, if any, modifications. Completing this form is not a guarantee of receipt of a vehicle – it is only a step in the application process. In order to be eligible for the Wounded Wheels program, applicants must not be a prior recipient of a Wounded Wheels vehicle and must meet the following criteria:

1) Must be able to drive a normal configured four-wheel vehicle, with no or minor modifications (i.e. less than $1,000parts and labor).

2) Must be a Purple Heart recipient and meet one of the following criteria:

(a) On active duty and recognized by the military service as disabled.

(b) Medically retired by a military service with 30% or greater disability.

(c) Retired military service with 30% or greater disability, determined by the Veterans’ Affairs Office.

(d) Discharged honorably with 30% or greater disability.

3) In addition,applicants must meet general moral and ethical standards which may include, but are not limited to, the following:

(a) No felony convictions.

(b) No outstanding wants or warrants.

(c) Any other discriminatory conduct as determined by the selection panel.

Please provide the following:

Name (First, Middle, Last): / Address:
Phone:
Email:
Branch of Service: Army___; Navy___; Air Force___; Marines___; Coast Guard___; Other(specify):___
Conflict: Vietnam___; Grenada___; Panama___; Persian Gulf___; OEF___; OIF___; Other(specify):___
Dates Served:______to______/ Rank and Rate(current,
at discharge, or at retirement):
Combat Duty: Yes____; No____ / Injury Sustained/Percentage Disability:
Campaign
Badges: / Honors and/or
Citations:

Please tell us your story and about your injuries:

Will vehicle modifications be necessary for you to drive the vehicle?Yes____; No____;

If yes, what modifications are necessary?

May we post your story on our website or other social media? Yes____; No____;

If yes, how do you wish to be represented: Use Your First Name and Last Initial____; Don’t Use My Name____;

Note: If we don’t use your name, a fake name will be used (example: John D.)

What do cars mean to you/why do you want a classic car?

I understand that the information provided on this form is private, and shall be held in strict confidentiality. I also agree that all the information above is correct to the best of my knowledge and hold harmless Wounded Wheels, its Directors, and Employees from any liability, loss, claim, cost or damage of any nature.

Sign:______Date:______

You may submit your application by mailing itto Wounded Wheels, 2400 Hampton Blvd Suite A, Norfolk, VA 23517 or submitting it via email to . For more information,call our office at (757) 609-0507 or visit our website at