Owner Information

Your Name (First and Last):

Street Address:

City:

State:

Zip:

Cell phone:

Daytime Phone:

Required

Email Address:

Required

Vehicle Information

Make

Model Description

Year

Approx. Mileage

Plate Number

VIN
(Vehicle Identification Number)

Condition of body including any damage.
Please be as specific as possible.

Condition of interior including any damage.
Please be as specific as possible.

Does the vehicle run/drive well? (if not, please describe what is known about its running condition.)

Have Title? Name(s) on title.

Required

Is your registration current? If not, what year did you last pay your registration fee?

Location of vehicle & contact person.

(Please note, if your vehicle is in a different location than your above address, please give that address here as well as the name and phone number of the contact person if available.)

We do not pick up in Mississippi.

Thank you for your participation in Car Donation Charities.

We will process your form and then you will be contacted very soon by email.

Please stay alert for email responses.