DOMESTIC REQUEST

Domestic Shipping Request

Contact Information

Organization Information

Shipping Address, if different (cannot be a P.O. Box)

Does the organization have funds available to cover the cost of shipping and handling? *

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Briefly list the type and the approximate quantity of items the organization is requesting (for example, 1 pallet of ENT supplies or 10 boxes of ostomy supplies).

O U R   O F F I C E

D O N A T I O N    H O U R S

Mondays: 8:30 AM - 4:00 PM

Thursdays: 2:00 PM - 4:00 PM

Tuesdays, Wednesdays &

Fridays: By Appointment Only

H O W   T O

S U B S C R I B E

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