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GreenVehicleDisposal.com Vehicle Pick Up Request Form
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Owner Information Section
Name *			Province / State *	Please select... Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ---------- Alaska Alabama Arkansas Arizona California Colorado Connecticut Washington D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
Address on Ownership *			Postal / Zip 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?
Yes, I want to donate my vehicle.			Please select your Charity from this list. Rainbows Canada Children's Wish Foundation of Canada Children's Aid Foundation of Canada Zoocheck Canada Food Banks Canada Canadian Cystic Fibrosis Foundation Epilepsy Ontario Interval House Toronto Cat Rescue 10,000 Trees for the Rouge Abbey Cat Adoptions Alzheimer Society of Oxford Amici Camping Charity AUTISM ONTARIO BRANDON STREET COMMUNITY DEVELOPMENT PROJECT Broad Reach Foundation Camp Winston Camp Trillium Canadian Cancer Society CANADIAN DIABETES ASSOCIATION Canadian Liver Foundation Child Find Ontario Community Association for Riding for the Disabled COVENANT HOUSE TORONTO CROHN'S AND COLITIS FOUNDATION OF CANADA DEBRA of Canada Durham City Basketball Association Easter Seal Society English Springer Rescue Association of Canada Family Association for Mental Health Everywhere Heart and Stroke Foundation of Ontario House of Sophrosyne Junior Achievement of Central Ontario Juvenile Diabetes Research Foundation Canada Learning Disabilities Association of York Region Lupus Ontario Make-A-Wish® Toronto & Central Ontario Mississauga Food Bank Opération Enfant Soleil Parents in Transition Pelletier Homes for Youth Procure Reach for the Rainbow Reptile Rescue and Education Society Scouts Canada East Scarborough Scripture Union Canada Second Chance Wildlife Sanctuary The Sickle Cell Association of Ontario Street Cats Sunshine Foundation of Canada The Teresa Group Thyroid Foundation of Canada TREE CANADA White Ribbon Campaign Woodgreen Red Door Family Shelter Choose Your Own Licensed Charity
Choose your own favorite Registered Charity:
(Is your Charity Not Listed?) Please type the name of the Licensed Charity.
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 Disposal program. We will process your form and then you will be contacted very soon by email or phone with reference to the pricing for your vehicle and pick up arrangements.

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