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Donation Form
Name:
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Address:
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City:
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ZIP
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Email
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Phone:
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Have You Donated A Car Yet?
Yes
No
How Would You Rate Our Service?
(1 being worst and 10 the best)
1
2
3
4
5
6
7
8
9
10
Are you planning to donate a vehicle in the future?
Yes
No
If so, how long from now?
Not Donating
Less than One Month
1-2 months
2-3 months
3-6 months
More than 6 months from now
What kind of vehicle would you be donating?
(check all that apply)
Car
Truck
Van
Boat
Other
Make of Vehicle:
Model of Vehicle:
Year of Vehicle:
Comments:
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