In Association With:
GreenVehicleDisposal.com Vehicle Donation and Pick Up Request Form
Click here to learn more about the Charity Car Program.
Owner Information Section
Name *			Province *	Please select... Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
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 Dystrophic Epidermolysis Bullosa Research Association of Canada
Vehicle Information Section
Year			Make
Model			Mileage
Licence Plate			VIN #
Location of vehicle if different than the address above.
Condition of vehicle	Please choose one.WorkingNot Working		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.