Rogue Valley Humane Society
P.O. Box 951
Grants Pass, OR 97528
541-479-5154

Date_______________________

Donor Name ______________________________________________________________

Mailing Address ___________________________________________________________

City _______________________________________ State _______ Zip _______________

Phone # ___________________________ Alternate # ______________________________

Vehicle Location (If different than above) _________________________________________________________________________

City _______________________________________ State _______ Zip _______________

Vehicle Information:

Year _________ Make __________________ Model ______________________________

VIN # ____________________________________________ License # _______________

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 any problems/damage:
Engine __________________________________________________________________
Trans. __________________________________________________________________
Tires ___________________________________________________________________
Body ___________________________________________________________________
Other __________________________________________________________________

Special Instructions: __________________________________________________________

____________________________________________________________________________

Website: www.roguevalleyhumanesociety.org

Email: rvhs@budget.net