Car Donation Form

MedWish International Car Donation Form
Date:

MonthDayYear
Donor Name:

First NameLast Name
Vehicle Location:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:

Area CodePhone Number
Alternative Phone Number:

Area CodePhone Number
Mailing Address (If different than above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Vehicle Information
Year:
Make:
Model:
License Number:
VIN#:
Please check all that apply:
If no, please explain:
Damage to Body (Describe):
Damage to Interior (Describe):
Problem with Engine or Transmission (Describe):
Is the vehicle run driveable?
Should be Empty: