1) SELECT THE FONDATION

	Kidney Car
	MIRA Fondation
	Others (To come...)

Your old jalopy will be recycled in accordance with the strictest environmental standards, and 100% of its value will be donated to the selected organization.

Contact us:
-Montreal's South Shore, the Laurentians, Lanaudiere, Vaudreuil-Soulanges and Monteregie, Metropolitan Montreal, the Lower Laurentians, Oka, Mirabel, St Jerome: 514-325-7346

- Mauricie/Centre du Quebec, Trois-Rivieres and Shawinigan: 1-819-378-1369

-Outaouais (Gatineau, Hull, Buckingham, Papineauville, Montebello, Aymer and Chelsey) : 819-643-0056

Towing is free within a 60 km radius of these cities. If you bring your car to us, we'll add $50 to the tax receipt.



1)DONOR INFORMATION

Mr.

Ms.

Language of correspondence:

French

English

Last name *

First name *

Address

Apt.

City		Postal code
Home phone		Work phone

2) INFORMATION ABOUT THE CAR BEING DONATED

Type of vehicle		Make
Model		Year
Licence plate		Serial number (VIN)
Colour		Odometer reading

Miles

Kilometres

A) Is the car registered in your name ?	Yes		No
B) Is the car fully paid off and free of outstanding debts ?	Yes		No
C) Is your vehicle registration still valid ?	Yes		No

3) TOWING INFORMATION

Specify the address where the vehicle will be picked up.
Contact *

Day phone no.:

Evening phone no.:

4) TERMS AND CONDITIONS

I hereby attest that I am the rightful owner of the vehicle mentioned in article 3 above and that I wish to
transfer it completely and definitively to the Foundation. *

For more information, call 1-877-688-0588.