Survey - Donate a Car | Alzheimer's Association

1.

Name data

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First Name: Required

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Last Name: Required

*

Email: Required

*

Street 1: Required

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City/State/ZIP:

City Required	State Required	ZIP Required

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Phone Number: Required

Yes, I would like to receive updates from the Alzheimer's Association

Yes, I would like to receive postal mail from Alzheimer's Association

2.

Question - Not Required - Vehicle at same address?

3.

Question - Not Required - Vehicle Address

4.

Question - Not Required - Vehicle City

5.

Question - Not Required - Vehicle State

6.

Question - Not Required - Vehicle ZIP

7.

Question - Not Required - Yehicle Year

8.

Question - Not Required - Vehicle Make

9.

Question - Not Required - Vehicle Model

10.

Question - Not Required - License Plate #

11.

Question - Not Required - VIN

12.

Question - Not Required - Damage to body (describe)

(Maximum response 255 chars, approx. 5 rows of text)

13.

Question - Not Required - Damage to interior (describe)

(Maximum response 255 chars, approx. 5 rows of text)

14.

Question - Not Required - Is your vehicle drivable as is?If not, please explain.

(Maximum response 255 chars, approx. 5 rows of text)

15.

Question - Not Required - Do you have the certificate of title?If not, please explain

(Maximum response 255 chars, approx. 5 rows of text)

16.

Question - Not Required - Special instructions or other comments:

(Maximum response 255 chars, approx. 5 rows of text)