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STEP 1
STEP 2
STEP 3
Let's Begin
Tell us about yourself.
Select a title (required)
Mr.
Ms.
Mrs.
Dr.
Prof.
The
Mr. & Mrs.
Must be in form NN.
i.e. "MD" = "Maryland"
Select a county
Alameda
Albemarle
Alexandria
Allegany
Amelia
Anne Arundel
Arlington
Baltimore City
Baltimore County
Bedford
Berkley
Buckingham
Calvert
Caroline
Carroll
Cecil
Charles
Charlottesville
Chesterfield
Clarke
Colonial Heights
Culpeper
Cumberland
Dinwiddie
Dorchester
Fairfax
Falls Church
Fauquier
Fluvanna
Franklin
Fredericksburg
Frederick, MD
Frederick, VA
Garrett
Gloucester
Goochland
Greensville
Hampton
Hanover
Harford
Henrico
Hopewell
Howard
James City
Jefferson
Kent
King George
King William
Loudoun
Louisa
Lynchburg
Madison
Manassas
Mathews
Middlesex
Montgomery County MD
Montgomery County VA
New Kent
Newport News
Norfolk
Northampton
Northumberland
Orange
Page
Petersburg
Portsmouth
Powhatan
Prince Edward
Prince George's County MD
Prince George, VA
Prince William
Queen Anne's
Rappahannock
Richmond
Roanoke
Shenandoah
Somerset
Spotsylvania
St. Mary's
Stafford
Suffolk
Sussex
Talbot
Virginia Beach
Waldorf
Warren
Washington
Washington D.C.
Westminster
Westmoreland
Wicomico
Williamsburg
Winchester
Worcester
Other
On to step 2
Vehicle Location
Where is your donation located?
Vehicle location same as residence? (required)
Yes
No
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Vehicle Information
Tell us about your vehicle.
Make (required)
Acura
Audi
BMW
Buick
Cadillac
Chevrolet
Chrysler
Dodge
Eagle
Ford
Geo
GMC
Honda
HUMMER
Hyundai
Infiniti
Isuzu
Jaguar
Jeep
Kia
Land Rover
Lexus
Lincoln
Mazda
Mercedes
Mercedes Benz
Mercury
MG
MINI
Mitsubishi
Nissan
Oldsmobile
Other
Plymouth
Pontiac
Porsche
Saab
Saturn
Scion
Smart
Subaru
Suzuki
Toyota
Triumph
Volkswagen
Volvo
Include designation i.e. LX, EX, GT
VIN can typically be found on the title or on the upper left-hand corner of dash (driver's side)
Vehicle Runs:
Yes
What's the general condition?
Please list any mechanical problems the car currently has or has had in the past.
Detailed information is needed to evaluate how your donation will be used in our program.
Interior
Check all that apply.
Detailed information is needed to evaluate how your donation will be used in our program.
Unchecked boxes will indicate to VFC that the item does not apply to your vehicle.
Leather seats
Power seats
Carpet is very dirty, stains
Holes/cracks in seats
Air conditioning works
Sunroof functional without leaks
Exterior
Check all that apply.
Detailed information is needed to evaluate how your donation will be used in our program.
Unchecked boxes will indicate to VFC that the item does not apply to your vehicle.
2 Door
Faded Paint
Major body damage - More than $2000 needed to repair
Minor scratches and/or dents
All lights are in working order
Windshield is fine
4 Door
Power side & rear door - van only
Exterior is in very good condition - almost like new
All 4 tires are inflated
Major scratches and/or dents
Runs
Mechanical
Check all that apply.
Unchecked boxes will indicate to VFC that the item does not apply to your vehicle.
Transmission
--None--
Auto
4
5
6
Engine has no known problems
Vehicle overheats
Engine runs but very rough
Car well maintained including oil change every 3 months
Is this a one-owner vehicle?
Transmission shifts smoothly
Vehicle will need a jump start
Engine doesn't even run with jump
Was timing belt replaced?
Service engine light on
4WD/AWD
Miles when timing belt was replaced:
Miles when engine was replaced:
Miles when transmission was replaced:
How Long Has Vehicle Been Sitting?
Go Back
On to step 3
Final Steps
What is the Social Security Number
of the donor?
What is your social security number?
If you don't want to provide your number, please put "100-00-0000" in this box.
"IRS Requirement: In order to claim your tax deduction, you must provide your Social Security Number. This information is kept confidential."
View IRS Document
Is it safe to enter my Social Security Number?
Last Question
We'd like to know how
you heard about us.
How did you hear about Vehicles For Change?
Select a source (required)
School
Organization
Dealer/Repair Shop
Internet
Event
Radio
Television
Newspaper/Publication
Miscellaneous
Select a specific source (required)
--None--
Donation
Trade In
Purchase
Return/Repo
--None--
Fax
Mail
Online Form
Phone Call
Walk-In
--None--
Applicant
Donor
Buyer
Marketing
--None--
Direct Mail
PPC Campaign
Website
Yahoo
Go Back
Complete Donation
Vehicles for Change Partners
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4111 Washington Blvd., Halethorpe, MD, 21227
855-820-7990 |
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