| Donor
Information |
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| Name:
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E-mail:
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| Phone:
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Address:
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Alternate Phone:
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City:
Zip:
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State:
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Choose
Your Charity
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Vehicle Information
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Vehicle Address: (write same
as above if the same)
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City:
Zip:
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State:
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Vehicle
Make:
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Vehicle
Model:
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Vehicle
Mileage:
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Vehicle
Year:
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Vehicle
Color:
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Other
Color:
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Damage
to Body (Describe):
Damage to Interior (Describe):
Is the vehicle drivable as
is? If not, please explain:
Do you have the Certificate
of Title? If not, please explain:
Special Instructions
or Other Comments:
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| Having
Trouble with this form? Send your info
in an email to:
info@pickyourcharity.com |
