Fondation Cite De La Sante

Fondation Cite de la Sante focuses on improving the quality of the care and the services provided to the patients of the Cite-de-la-Sante Hospital and the Health and Social Services Centre (CSSS) of Laval with the purchase of high technology medical equipment. It also promotes knowledge acquisition pertaining to the health field and supports research in general and specialized care while contributing freely to the quality of life of the patients.

Vehicle Donation Quotation Form
Please note: By filling out the form below you are not committed to donating your car. Filling out this form will allow us to contact you with a quote on the price the charity of your choice will receive for your vehicle. All personal data is kept strictly private and will never be sold.
Owner Information Section
Name *	State/Province *
	Please select... ---- Canada ---- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ---- USA ---- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Address on Ownership *	ZIP/Postal Code *
City *	Phone Number *
Cell Number	Email *
Donating Your vehicle?
Yes, I want to donate my vehicle to Fondation Cite De La Sante.
Vehicle Information Section
Year	Make
Model	Mileage
License Plate	VIN #
If your vehicle is located at a different address from your home address, please check the box and then complete the following section, if same as home address (skip) Address* ZIP/Postal Code * City * State/Province * Please select... ---- Canada ---- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ---- USA ---- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Condition of vehicle	Comments about vehicle
Please choose one. Working Not Working
There are no liens / loans outstanding against this vehicle.
I do have the ownership / title to transfer to the Authorized Treatment Facility.
Human? Answer this question 4+7=