| All fields with
an asterisk are required. |
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| First Name :
* |
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| Last Name : * |
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| Company : |
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| Address 1 : * |
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Address 2 :
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| City : * |
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| State : * |
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| Zip/Postal
Code : * |
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| Country : |
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| Home Phone :
* |
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| Daytime Phone
: * |
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| Ext : |
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| Email : * |
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| How
did you hear about Marklund’s vehicle donation program? |
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| To help us
process your donation, please complete the form below.
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| Information
about the vehicle |
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| Type of
Vehicle (boat, car, RV, lawn mower, etc.) : |
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| Year of
Vehicle : |
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| Make of
Vehicle : |
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| Model : |
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| Color : |
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| VIN : |
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| Vehicle
Mileage (or hours for lawnmowers, snowblowers, etc.) : |
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| Vehicle
Specifics (two-door, four-door, wagon, etc.) : |
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| Is the
vehicle drivable? : |
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| Do you have a
title? : |
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| Location
of Vehicle |
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| Address : |
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| Where is it
parked? : |
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| Is the
vehicle blocked in? : |
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| Is it
accessible 24 hours? : |
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| Envelope with
Keys and Title will be located in the : |
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| Brief
description of any necessary mechanical or cosmetic repairs : |
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| Do you wish
to be present at pick-up time? : |
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Thank
you. |
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