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MDM Auto Donor Survey

1. Personal Information

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Name:

 

 

 

     

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City/State/ZIP:

 

    

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If you respond and have not already registered, you will receive periodic updates and communications from National MS Society.

 

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  Title Information
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  Vehicle Information
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19.
Question - Not Required - Mechanical Condition (1= Poor, 5= Excellent)





20.
Question - Not Required - Body Condition (1= Poor, 5= Excellent)





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*22.
Question - Required - How did you find out about this donation program?
Please make between 1 and 5 selections from the choices below.

   Please leave this field empty