Page 67 | Countryside Baptist Church of Dover, Inc.

Name (Required)

Email Address (Required)

Mobile Phone Number (Please Provide to Opt in for Text Updates)

Are you a single mom or widow currently residing in Hillsborough County Florida? (Proof of Residency May Be Requested) (Required)

Proof of Residency requests may include Driver License, Utility Bill, or Proof of Insurance.

Please select your current income level from the list below.

Address (Hillsborough County Residents Only) (Required)

VIN- Vehicle Identification Number for Vehicle Requiring Oil Change (Please Type in ALL CAPS) (Required)

This field is necessary to ensure appropriate oil, oil filter, and tools are available.

Please type Year, Make, Model of Vehicle requiring oil change. (Example: 2004 Toyota Camry) (Required)

Providing this information will allow us to verify we have correct VIN Number as well.

Are you willing to sign an authorization for work to be completed which will also release Countryside Baptist its officers, directors, and members from liability related to this oil change? (Required)

Countryside Baptist Church of Dover, Inc.

13422 Sydney Rd
Dover, FL 33527

(813) 571-8200

office@cbcdover.org

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