The Connecticut Humane Society: Survey

Connecticut Humane Society Vehicle/Vessel Donation Form

* You will be contacted by Car Program LLC within 2 business days.

Question - Not Required - Date:

Month

Day

Year

Donor Name/Vehicle Location Information:

*

Name:

First Required	Last Required	Suffix

Email:

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	State Required	ZIP Required

*

Phone Number: Required

If you respond and have not already registered, you will receive periodic updates and communications from The Connecticut Humane Society.

Remember me. What's this?

Question - Not Required - Alternate Phone Number:

Question - Not Required - Donor Mailing Address (if different than above):

Question - Not Required - City:

Question - Not Required - State:

Question - Not Required - Zip:

Vehicle/Vessel Information:

Question - Not Required - Year:

Question - Not Required - Make:

Question - Not Required - Model:

Question - Not Required - VIN/Hull #:

Question - Not Required - License/CF #:

Question - Not Required - Please check all that apply:
Please make between 1 and 4 selections from the choices below.

Question - Not Required - Does the vehicle run and drive as is right now?

Question - Not Required - If No, when was the last time the vehicle was driven?

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Do you have the Title?

Question - Not Required - If No, explain:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Please describe the mechanical condition of the vehicle:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Please describe any damage:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Special Instructions:

(Maximum response 255 chars, approx. 5 rows of text)

*

Question - Required - Donate proceeds to:
Please make 1 selection from the choices below.

	Connecticut Humane Society
	Fox Memorial Clinic

For more information contact Gay-Marie Kusznir at (860) 594-4502 x 6301 or by e-mail at gkusznir@cthumane.org.