Earth Share

Vehicle Donation Form

                     → Please complete and fax this form to Earth Share, 240.333.0301.

PLEASE NOTE: Once your donation is accepted, you will be contacted by a towing service within four business days at the latest. Your acknowledgement receipt will follow.

Date _______________________

Donor Name _________________________________________________________________

Phone #  ___________________________  Alternative #  _____________________________

Vehicle Location ______________________________________________________________

City _______________________________________ State  _______  Zip  _______________

Vehicle Information:

Year  _________  Make  __________________  Model  ______________________________

License # _______________  VIN # _____________________________________________

Please check all that apply:  ___ 2-Door   ___ 4-Door   ___ Station-Wagon    ___4-Wheel-Drive     

Does the vehicle run and drive as is?  ___ Yes  ___ No, explain____________________________

Do you have the Title? ___Yes ___ No, explain_______________________________________

Please note problems/damage:

Engine      __________________________________________________________________

Trans.       __________________________________________________________________

Tires         __________________________________________________________________

Body        __________________________________________________________________

Other       __________________________________________________________________

None        _____       

Special Instructions: ___________________________________________________________

____________________________________________________________________________

_____________________________________________________________________________________________________

Car Program LLC  *  3755 Omec Circle Unit #4  *  Rancho Cordova  *  CA 95742

tel (800) 513-6560  *  fax (916) 631-4336  *  info@carprogram.com