Donation of Mobility Assistance Vehicle – Mobility Vans for Kids (MV4K)

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Nameyour full name

Phone Number

Email Address

Street Address

Apt/Unit/Floor

City

State

Zip Code

Where is the mobility assistance vehicle currently located?

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What current modifications are currently installed in the mobility assistance vehicle?

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How did you find out about Mobility Vans for Kids?

I certify that all statements and information above is true and that I have read the application guidelines

Additional supporting information or comments:

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