Please be sure to have your title information available prior to filling out this form.
Route 128 Used Auto Parts & Sales' towing area encompasses Eastern and Central parts of Massachusetts.

Current location of the car (driveway, business, etc.) *

Address (Number, Street) *

City *

State *

Zip *

Do the tires have air in them? * Yes No

Title # *

VIN # (17 digits) *

State *

Owner's Name *

Contact Person's Name *

Home Phone # *

Work Phone #

E-mail Address (Required for receipt) *

Year *

Make *

Model *

Color *

Is the car running? * Yes No

Mileage

Please note any major mechanical problems

Was the car in any accidents? * Yes No

Body Damage

Rust * Yes No

Your Mailing Address (Number, Street) *

(Apt., Suite, Floor)

City *

State *

Zip *

How did you hear about the car donation program? *

Additional Questions or Comments

* Required