Eau Claire Co. Humane Assoc.

Vehicle Donation Form

· When complete, please fax this form to ECCHA at (715) 839-1664 or send it to:

ECCHA, 3900 Old Town Hall Rd. Eau Claire, WI 54701

· A towing service will call the donor within four business days (after ECCHA receives this form) to schedule an appointment.

Donor Information:

Date: _______________________

Name ______________________________________________________________________

Address (car’s location) _________________________________________________________

City _______________________________________ State _______ Zip _______________

Phone # ___________________________ Alternative # _____________________________

Vehicle Information:

Year _________ Make __________________ Model ______________________________

License # __________________ VIN # __________________________________________

Please check all that apply: 2-Door 4-Door Station-Wagon 4-Wheel-Drive

Does the vehicle run and drive as is? Yes No, explain____________________________

Do you have the Title? Yes No, explain_______________________________________

Problems:

Engine __________________________________________________________________

Trans. __________________________________________________________________

Tires __________________________________________________________________

Body __________________________________________________________________

Other __________________________________________________________________

None ___________________________________________________________________

Special Instructions: __________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

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