Donor Information
First Name:    
Last Name:    
Address:    
City:    
State:    
Zip:    
Daytime Phone:    ( ) -  
Alternate Phone:    ( ) -  
Email:    
   
Vehicle Location
    Check here if vehicle location is same as Donor address.   
Address:    
City:    
State & Zip:        
   
Vehicle Information
Year:    
Make:    
Model:    
License Plate:    
VIN:    
   
   Damage to Body (Describe):
   
   
   Damage to Interior (Describe):
   
   
   Is your vehicle drivable as is? If not, please explain:
   
   
   Do you have the certificate of title? If not, please explain:
   
   
   Special instructions or other comments.:
   
   
   How did you hear about the Dare vehicle donation program? Check all that apply:
    Radio Internet Search
    Flyer Other, please specify
    Newspaper
    Dare Officer
   
 

 

 
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