Please complete and mail, email or fax this form back to the Seattle Lighthouse

Mail: 2501 S Plum St
Seattle, WA 98144-4711
Fax: 206-329-3397
Email: mmueller@seattlelh.org
* You will be contacted within five business days after we receive this form.

Date _______________________

Donor Name _____________________________________________________________

Phone # __________________________ Alternative # __________________________

Vehicle Location _________________________________________________________

City _____________________________________ State _______ Zip ____________

Vehicle Information:

Year _________ Make __________________ Model __________________________

Plate # _________________ VIN # _________________________________________

Please check all that apply: 2-Door 4-Door Station-Wagon 4-Wheel-Drive

Does the vehicle run and drive as is? Yes No, explain______________________

Do you have the Title? Yes No, explain_________________________________

Please note problems/damage:
Engine ______________________________________________________________
Trans. ______________________________________________________________
Tires ______________________________________________________________
Body _______________________________________________________________
Other _______________________________________________________________
None

Special Instructions:

_______________________________________________________________________

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