Tracy Hospital Foundation Vehicle Donation Program
Please complete and fax this form to Tracy Hospital Foundation at 209-833-2345 or if you prefer, email to tracyhospitalfoundation@sutterhealth.org. The donor will be contacted within four business days.
Date __________________________
Donor Name_______________________________________________
Mailing Address _______________________________________________
City _________________________________ State ______Zip_________
Phone # _____________Alternate Phone # ________________
Vehicle Location (if different than above) _________________________________________
City _________________________________ State ____ Zip _______
Vehicle Information
Year _______ Make ____________________
Model ___________________________
VIN # ___________________________________________________
Please check all that apply:
______ 2-Door ______ 4-Door ______
Station-Wagon ______ 4-Wheel Drive ______
Does the vehicle run? ______
If not, explain ______________________________________
__________________________________________________
Please note any problems/damage:
Engine______________________________________________________
Transmission_________________________________________________
Tires ___________________________________________________________
Body ___________________________________________________________
___________________________________________________________
Other ___________________________________________________________
___________________________________________________________
Special Instructions ___________________________________________________________
___________________________________________________________
___________________________________________________________
505 West Beverly Place • Tracy, CA 95376 Telephone: 209-832-6052 • Fax: 209-833-2345