Donation Request Information Form

Donation Request Information Form
Complete this form if you are requesting donations such as clothing, shoes, or personal care items. Donation assistance is available once every 3 months per household.

Instructions:

Complete this form then contact our office to schedule an appointment to meet with a Donation Coordinator. If you cannot complete online we have this form available in the center to pick up. Once in our office you will complete one more form to address your specific need. You must be age 16 or older to complete a donation request.

**We cannot accept walk ins at this time due to Covid-19**
Name*

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Last 4 of SSN
You must provide the last 4 of your SSN in this field OR Full Driver's License/ID number in the next field below.
Drivers License OR ID Number
Please provide your DL or ID number in this field OR last 4 of SSN in the field above.
I am in need of:*

ClothingShoesPersonal Care Items
By signing I certify that it has been at least 90 days since my last request for donation. I certify that I am truly in need of donated items and I will not resell.

Clear
Should be Empty: