| *To WHICH CHARITY do you wish to donate?: * |
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| *How did you hear about NWCDS?: * |
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| If you selected OTHER, please specify here: |
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DONOR'S CONTACT INFORMATION: |
| *Donor FIRST Name: |
(REQUIRED) |
| *Donor LAST Name: |
(REQUIRED) |
| *Donor MAILING Address Street 1: |
(REQUIRED) |
| *Donor City: |
(REQUIRED) |
| *Donor State: * |
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| *Donor ZIP Code: |
(5 digits) (REQUIRED) |
| *Donor Daytime Phone: |
(REQUIRED) |
| Donor Alternate Phone: |
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| Donor Email: |
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| When is the best time for us to contact you?: |
(RECOMMENDED) |
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DONOR'S VEHICLE DONATION INFORMATION: |
| *Vehicle Year: |
(REQUIRED) |
| *Vehicle Make: |
(REQUIRED) |
| *Vehicle Model: |
(REQUIRED) |
| Vehicle Engine Size/Type: |
(If you are donating a boat.) |
| *Number of Doors: |
(REQUIRED) |
| *Vehicle Color(s): |
(REQUIRED) |
| Vehicle Mileage (odometer reading): |
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| Vehicle License Plate Number: |
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| Vehicle Identification Number (VIN-- it's on your title and registration): |
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| *Do you have the vehicle title and keys? |
YES NO (REQUIRED) |
| If you selected "NO", please explain:: |
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| *Does the vehicle run? |
YES NO (REQUIRED) |
| If vehicle does not run, please explain: |
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NOTE: If your vehicle's physical location is different from your address above, please enter it below: |
| Vehicle's Physical Street Address: |
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| Vehicle is located in what city?: |
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| Vehicle is located in what state?: |
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| Vehicle location ZIP Code: |
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Your charitable donations benefit charities throughout