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Dystrophic Epidermolysis Bullosa Research Association of Canada In Association With:
1877EndOfLife
GreenVehicleDisposal.com Vehicle Donation and Pick Up Request Form
Click here to learn more about the Charity Car Program.
Owner Information Section
Name * Province *
Address on Ownership *   Postal Code *
City *   Phone Number *
Cell Number   Email *
We respect your right to privacy, all information entered is strictly used for contact purposes in regards to this specific transaction.   
This information is confidential, only to the parties involved and will not be sold or redistributed to any third parties.

Donating Your vehicle?

 I want to donate my vehicle to

Vehicle Information Section

Year   Make
Model   Mileage
Licence Plate   VIN #
Location of vehicle if different than the address above.  
Condition of vehicle   I do have the ownership / title to transfer to the Authorized Treatment Facility.
There are no liens / loans outstanding against this vehicle.   Comments about vehicle

Thank you for choosing GreenVehicleDisposal.com's Vehicle Donation and Disposal program. We will process your form and then you will be contacted very soon by email or phone.

* denotes required field.


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