Teen Challenge Northern California / Nevada
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Vehicle Donation Form

By Philip Bailey
Vehicle Donations
* Required
First Name *
Last Name *
Email Address *
 
Address Line 1 *

Address Line 2
City *
State *
Zip Code *
 
Area Code
Phone Number
Home Phone *
Fax Phone
Work Phone
  Ext:
How Did You Learn About Our Organization?
 Radio
 Ad
 Church
 Friend
 TC Graduate
 Other
Vehicle Information
Type of Vehicle *
 Car
 Van
 Truck
 Other
Year: *
Make: *
Model: *
Color:
License Plate Number: *
VIN Number: *
Is the vehicle;s Title in your name? *
 Yes
 No
Pink Slip/Title? *
 Yes
 No
Salvage Title? *
 Yes
 No
Lien Papers? *
 Yes
 No
Complete with tires/ wheels/ engine transmission? *
 Yes
 No
Any flat tires? *
 Yes
 No
Has the vehicle been in an accident/burned/ flood? *
 Yes
 No
 Do not Know
Body Damage? *
Has all trash and personal belongings been removed?
 Yes
 No
Does vehicle start? *
 Yes
 No
Does vehicle have keys? *
 Yes
 No
Please fill out as much information as possible





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