Recycle for Gold Donation Form
Donor Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Vehicle Information
Is the car located at your home address?
*
Yes
No
Please Enter Car Location Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Vehicle Type
*
Car
Truck
Other
Vehicle Year
*
Vehicle Make
*
Vehicle Model
*
Vehicle Color
*
Odometer Reading
*
Title Number
*
Title Owners Legal Name(s)
*
VIN Number (Required for pick up)
*
Back
Next
Vehicle Condition
Vehicle Condition
*
Complete (engine, transmission, 4 tires) and running
Complete (engine, transmission, 4 tires) but not running
Not complete but has a running engine
Not complete not running
Is vehicle free of liens?
*
Yes
No
Do you have vehicle title?
*
Yes
No
Have plates been removed?
*
Yes
No
Vehicle may be sold. Is that OK?
*
Yes
No
Additional Comments
Submit
Should be Empty: