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Donate Your Vehicle

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Vehicle Donation Form

Title Information
Are you in possession of the title? Yes No			Is there a lienholder? Yes No
If yes, has the lienholder signed the title? Yes No

Donor Information
Donor First Name:*		Donor Last Name:*
Email:*		Home Phone:*
Mailing Address:		Apt#, Suite#:
Country:		State:
City:		Zip/Postal Code:
Work Phone:		Best Time to Contact:
Address of Vehicle:		Apt#, Suite#:
Country:		State:
City:		Zip/Postal Code:
Cross Streets:		Contact Person:

Vehicle Information
Vin#:		Year:
Make :		Model:

Problems:

Type of Car:			Color:
Does Vehicle Run?		Yes No	Battery?	Yes No
Engine/Parts In Place?		Yes No	Seats In Place?	Yes No
Accident?		Yes No	Wrecked?	Yes No
Radio?		Yes No	Cassette Player?	Yes No
Cd Player?		Yes No	Keys?	Yes No
Tires Inflated?		Yes No	Accessible To Tow?	Yes No
Referral Source Information
Heard Of Opportunity Village Before?		Yes No
Referral Source:
Enter the 5 digits from the image above in the box below: