Donor Information

E-mail Address:

Current Address

Street:
 

Cross Street:

Apt. #:

City: State: Zip:

*A valid phone number is required in order to submit this form*

Home Phone:

Work Phone:

Cell Phone:

Other Phone:

Is the vehicle located at the above address? Yes No

If not, indicate vehicle location below:

Location Name:

Address:

City:      State:      Zip:

Contact Person:

Contact Phone:

Vehicle Information

Year:

Make:

Model:

VIN:

# Doors:

Color:

Mileage:

Does the vehicle run? Yes No

To maximize the value from the donation of your vehicle, could you describe:

Condition of Interior:

Condition of Exterior:

Mechanical Condition (Please elaborate):

Do you have keys? No Yes

How do you rate the tires? Excellent Good Fair Poor

Are the tires inflated? Yes No

Does the vehicle have a battery? Yes No

Is vehicle accessible to tow truck and not parked in garage or grassy area? Yes No

Title Number:

Title state:

Title Control Number:

Is there or has there ever been a lien on the vehicle?  Yes No

On the front of the title, if there is a financial institution listed, you will be required to have a lien release

When your vehicle is picked up by our towing company, where would you like us to leave the receipt? (example: mailbox, under door, mail to me).

How did you hear about The Maryland School for the Blind?

Comments:

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