Please fill in the information below. Fields in bold are required. Donor Information First Name Last Name Street Address City State Zip Code Home Phone Work Phone E-mail Would you like a tax-deductible receipt upon the sale of the vehicle for the amount of the sale? Yes No Vehicle Year Vehicle Make Vehicle Model Registration Tags expire or expired Do you possess the registration pink slip? Yes No Is the vehicle driveable? Yes No List any vehicle problems: How did you hear about us? What code is in the image? * Enter the characters shown in the image.