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IMPORTANT IMPORTANT Please fill out this form and return

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IMPORTANT IMPORTANT Please fill out this form and return Powered By Docstoc
					                                        IMPORTANT
                Please fill out this form and return it to the Red Door Animal Shelter, P.O. Box 269119,
                Chicago, Illinois 60626 along with: 1) The signed title; 2) Social Security
                Number/Employer Identification Sheet.


Your Name _____________________________________________________________________________

Age (optional): <18_______ 18-24_______ 25-34_______ 35-44________ 45-54_______ 55+________

(MUST PROVIDE) Daytime Phone Number _________________________________________________

Description of Vehicle:
Make______________________________________ Model ______________________________________

Year________________ Color____________________________________________________________

Exact location where vehicle will be available for towing:
Address________________________________________________________________________________

City/State/Zip___________________________________________________________________________

                             @
Check one, or indicate Aother@ in detail:
‘ Driveway                 ‘ Garage                ‘ Yard         ‘ Street

‘ Other_______________________________________________________________________________

If vehicle has a flat tire(s), please check which one(s): Front Rear

Note: Be sure to remove all personal items from the vehicle and place the keys in the (indicate which):
‘ Ashtray        ‘ Glove Compartment         ‘ Console      ‘ Under Floor Mat

‘ Other (explain): _______________________________________________________________________

Is the vehicle drivable?     ‘ Yes    ‘ No
Briefly list needed repairs or body damage:____________________________________________________
______________________________________________________________________________________

On a scale of 1 to 10, please rate the exterior condition of your vehicle:
‘1    ‘2     ‘3                  ‘4     ‘5 ‘6 ‘7                             ‘8     ‘ 9 ‘ 10
      Poor                               Average                                  Excellent

On a scale of 1 to 10, please rate the interior condition of your vehicle:
‘1    ‘2     ‘3                  ‘4     ‘5 ‘6 ‘7                             ‘8     ‘ 9 ‘ 10
      Poor                               Average                                  Excellent

Where did you hear about our car donation program?___________________________________________

For Office Use Only
CONTROL #____________________

				
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