Car Donation Form

Last Name:
First Name:
Business Phone: (No Hyphens)
Home Phone: (No Hyphens)
E-Mail:
Address 1:
Address 2:
City:
State:
Zip Code:

Select a Charity

I would like my donation to benefit (select one): Please Select American Red Cross of Massachusetts Bay Angel's Gate Association for Help for Retarded Children Association for the Advancement of the Blind and Retarded Boy Scouts of America, Boston Minuteman Council Boy Scouts of America, Theodore Roosevelt Council Glaucoma Foundation Green Chimneys Huntington Hospital Island Harvest Kiwanis Club of the Five Towns Kiwanis Pediatric Trauma Center League for the Hard of Hearing Long Island Council for Alcoholism & Drug Dependence Mary Louis Academy Medical Society of the County of Queens Moment Magazine Mt. Baker Planned Parenthood Nassau County Sports Commission National Association of Mothers' Center Options for Community Living, Inc. Planned Parenthood of Nassau County Planned Parenthood of South Central New York Reconstructionist Congregation Beth Emeth Serve the Handicapped South Shore Association for Independent Living Temple Beth-El of Northern Valley Temple Emanu-El of Lynbrook Temple Rodeph Torah Terence Cardinal Cooke Health Care Center The Spinal Cord Foundation Thursday's Child

Vehicle Information

Year:
Make:
Model:
VIN:
Mileage:
Is the vehicle running?: Please Select Yes No
Condition of body (please describe):
Problems (engine, transmission, tires, other):
Condition of interior (please describe):
Do you have the Certificate of Title?: Please Select Yes No

Vehicle Location (If same as above please leave blank)

Address 1:
Address 2:
City:
State:
Zip Code:

Boat Information

Year:
Make:
Model:
Condition of Boat (please Describe):
Trailer Included?: Please Select Yes No

Miscellaneous Information

Special Instructions or Other Comments: