Car Donation Form

First Name *

Last Name *

Phone Number *

Phone Number Type

Company

Mailing Address

Mailing Address (Cont.)

Country

State/Province

City

Zip/Postal Code

Alt. Phone Number

Alt. Phone Number Type

Email Address

Vehicle Type

VIN/HIN

Year

Make

Model

Miles

Color

Vehicle Condition

Engine Condition

Transmission Condition

Tire Condition

Body or Paint Damage

Interior Damage

State of Registration

License Plate #

License Expiration Date

Name on Title

Titling State

ID # on Title

Is The Title Clear?
Yes No

Other Damage

Air Bag(s) Deployed

Fire Damage

Flood Damage

Mold

Other*

Severe Undercarriage Rust

Won’t Pass Smog/State Inspection

Is the vehicle located at your address provided above?
Yes No

Vehicle Address

Vehicle Address (cont.)

Country

State/Province

City

Zip/Postal Code

Contact Phone Number

Contact Phone Number Type

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