Mask Program Donation Request
To apply for our donation program, please complete the application below. A member of our team will be in touch to discuss your application and answer any additional questions you may have. Please note that your application does not guarantee that masks can or will be donated to your organization. Please refer to our donation page for additional information on how organizations are being selected.
What is the name of your organization?
Are you a non-profit?
How many masks are you requesting?
Are you willing to accept a lesser quantity if selected?
Yes
No
Requested Delivery Date (please note that this cannot be guaranteed even if your organization is selected)
-
Month
-
Day
Year
Date
Please describe how these masks will be used to benefit our communities and those we mutually serve.
Are you willing to report the impact of this donation to help spread awareness of the communication barriers caused by mask usage and the options available to overcome them? If so, how?
If you are not selected for our donation program, are you interested in our special pricing discounts for nonprofit/educational facilities?
Yes
No
Your Name
First Name
Last Name
Email
example@example.com
Website For Your Organization
i.e. www.adcohearing.com
Phone Number
-
Area Code
Phone Number
Primary Address for Organization (not for shipping purposes)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
Should be Empty: