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Car Donation

First Name :
Last Name :
Address :
City :
County :
State :
Zip :
Day Phone :
Evening Phone :
E-Mail :
Best way/ time to reach you :

Location of Vehicle :	Check here if location is same as above
Address :
City :
State :
Zip :

Please tell us how you would like to help our cause :

Vehicle Information :

Vehicle Type :	Car			Truck
Vehicle Specs :	2 Door	3 Door				4 Door
	4 Cylinder		6 Cylinder		8 Cylinder
Year :
Make :
Model :
Approximate Mileage :
License Plate :
VIN :
Vehicle color :
Title number :
Title state :

Out of state title /Pink Slip? :	Yes			No
Junk Slip? :	Yes			No
Application for duplicate title? :	Yes			No
Registration Current? :	Yes			No
Plates on/off? :	On			Off
Vehicle Driveable? :	Yes			No
Does Vehicle start? :	Yes			No
Is Vehicle complete? :	Yes			No
Keys available? :	Yes			No
Flat tires? :	Yes			No
Parked in street? :	Yes			No
Plates on vehicle? :	Yes			No
Damage :





Damage to body (exterior-please describe) :

Damage to interior (please describe) :

Is the vehicle driveable as is? If not, please explain :

Do you have the certificate of title for this vehicle? If not, please explain :

Is your registration current? If not, please explain :

Would you prefer a tax receipt or coupons/ vacations/ cruises? :

Special Instructions or comments :