Fillable Printable Car Donation Form - Outreach
Fillable Printable Car Donation Form - Outreach
Car Donation Form - Outreach
Vehicle Pick-Up Request
OUTREACH and Escort, Inc. 926 Rock Ave, Suite 10
San Jose, CA 95131 (408) 436-2865 Fax (408) 382-0470
DONOR INFORMATION:
Date: _____ / _____ / _____
N
ame: _________________________________________________________________
Home Address: _______________________________________________________
City: _______________________ State: ____________ Zipcode: ________________
Daytime Phone #:(___) ________________ Alternative # (__ ) __________________
VEHICLE INFORMATION:
Year: _______________ Make: _________________ Model: ___________________
Type / # Doors: ____________________ Color:____________ Mileage:____________
Automatic or Manual #Cylinders_______
License Plate #: _____________________ State: _______________________
Is the car running and is it safe to drive at least 50 miles? Yes / No
Will it require a tow truck? Yes / No
Do you have the title? Yes / No Is it registered to you?_______________________
When will the registration expire?____________________________
Vehicle Location Pick-up / Cross Street: ____________________________________
_
____________________________________________________________________
VEHICLE CONDITION:
Mechanical Problems: ____________________________________________________
_
______________________________________________________________________
Exterior Condition: Good / Fair / Poor ______________________________________
Interior Condition: Good / Fair / Poor
___________________________________________
How did you hear about our program?________________________________________
Please call (408) 436-2865 if you have any questions.
