Date: _________________
Donor Information:
Name __________________________________________________________________
Address ________________________________________________________________
City _________________________________ State _______ Zip ________________
Phone # _______________________ Alternative # ____________________________
Vehicle Information:
Year _________ Make _______________ Model _____________________________
VIN ________________________________ License _____________ Odom. ________
Please check all that apply: __2-Door __4-Door __Station-Wagon __4-Wheel-Drive __RV __Boat
Does the vehicle run and drive as is? __Yes__ No, explain________________________
Do you have the Title? __Yes ___No, explain___________________________________
Interior: __Excellent __Good __Fair __Poor
Body Damage: __None __Front End __Rear End __Driver Side__Passenger Side
Problems:
None _____________________
Engine _____________________
Transmission _____________________
Tires _____________________
Other _____________________
Special Instructions: ______________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please email, fax or mail this form to the Placer SPCA:
administration@placerspca.org -----fax 916-782-8655
150 Corporation Yard Rd. Roseville, CA 95678