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AUTO DONATIONS

Donor Information

Name *

Address *

Street Address *

Address Line 2

City *

State / Province / Region *

Postal / Zip Code *

Country *

Daytime Phone Number *

### - ### - ####

Alternative Phone Number

### - ### - ####

Email

Vehicle Information

Year *

Make *

Model *

Type/# of Doors *

Color *

Mileage *

Automatic or Manual/#Cylinders *

License Plate # *

State *

Is the car running and is it safe to drive at least 50 miles? *

Yes   No

Will it require a tow truck? *

Yes   No

Do you have the title? *

Yes   No

Is the car registered to you?

When will the registration expire? *

Vehicle Condition

Mechanical Problems? *

Yes   No

Explain:

Exterior Condition: *

Good   Fair   Poor

Explain:

Interior Condition: *

Good   Fair   Poor

Explain:

How did you hear about our program? *

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