Vehicle Donation

Thu, 04/07/2011 - 1:58pm — brockway

STOP Foodborne Illness
Tax I.D. # 33-0627613

* Indicates a required field

Date: *

Donor Information

Donor Name: *

Address: *

City: *

State: *

Zip: *

Daytime Phone#: *

Alternative Phone#:

Vehicle Information

Vehicle Location: *

City: *

State: *

Zip: *

Year: *

Make: *

Model: *

License#:

VIN#: *

When entering your VIN make sure that you enter 1 and 0 if appropriate. The letters I and O are not valid in a VIN.

Please check all that apply:

2 Door

4 Door

4 Wheel Drive

Station Wagon

Does the vehicle run as is?: *

If No, please explain:

Do you have the Title?: *

If No, please explain:

Please note problems/damage

Engine:

Transmission:

Tires:

Body:

Other:

Special Instructions:

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…America’s Voice for Safe Food