CR Daybreak Rotary         Donate-a-car Program

Donate a car registration

Please fill the form below, scroll down and click 'send' button.


Alternatively you may  download an Adobe form that you can print, fill out and Fax to us. Click here to download the Adobe form.

   
   

Contact Information:

  

First Name:

Last Name:

Phone:

Email:

Address:

City:

Province:

Postal Code:
   

Vehicle Information:

  

Year:

Make:

Model:

 VIN:
License Plate:
  

Is there any Damage to the outside? (Describe):

Is there any Damage to the inside? (Describe):

Does the vehicle run?:

Do you have the registration?:


Other Information:
 

Comments (please note other club affiliation and contact phone numbers):

Rotarian Name:

Rotarian Email:
   
Were you referred to the program?
 If yes, by whom were you referred?