VFD Vehicle Donation

Applicant Information

VFD Information

Legal Name of Organization

Doing Business As

Email

Phone

Physical Address

Mailing Address

City/Town

State

ZIP

Website

Contact Information

Name

Position

Email

Phone

Organization Information

Approximately how many people are served?

Year Founded

Number of Volunteers

Paid Full-Time Positions

Paid Part-Time Positions

Check here if you are a 501(c)

Check here if you're required to submit a form 990

Check here if you're part of an Emergency Services District

If you're a 501(c), please provide your Employer Identification Number (EIN)

If a 990 is required, please upload your latest copy here.

Upload requirements

If you're part of an ESD, please list all ESDs and the average annual financial support received:

Application

How will a vehicle donation fulfill a need that helps further the goals and mission of the VFD?

Additional Information

Submit a copy of the budget for the current fiscal year.

Upload requirements

List all VFD vehicles, including make, model and approximate value.

List any completed or pending fundraising plans for the current fiscal year; include the amounts raised and what the monies were or will be used for.

Certification of Application

I understand by submitting this application that the VFD is not guaranteed a vehicle donation from Medina EC.

I am also certifying that this application is complete and the information provided is complete and accurate.

I understand that if the VFD I am representing does receive a vehicle donation that the:

Requesting VFD must assume all liability for the fitness for duty and usefulness of the donated vehicle to the operation of such entity
Requesting VFD accepts vehicle in “as-is” condition with no warranty conveyed
Requesting VFD assumes responsibility for all tax, title and license impact of donated vehicle
Requesting VFD cannot use the donated vehicle for the purposes of fundraising and/or raffling
Requesting VFD must give consent to allow a photograph and/or video of the donation with at least one member of the VFD
Requesting VFD must give consent to media presentation of donation
If awarded a truck, a required five-year waiting period is required before the VFD can be considered for a truck donation

Type Name

Signature

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