Donation Request Form GDD

Donation Request Form

GDD Pharmacy Services Inc.
To be considered for a charitable donation for your organization located in the neighborhood of one of the pharmacies in our group, please complete the form below.

Our family of independent pharmacist owned pharmacies: Harrisburg Pharmacy, Good Day Pharmacy, See-Right Pharmacy, Pine Grove Pharmacy, Cumberland Apothecary.
Organization (If applicable)
Street address:
Street address line 2:
City:
State:
Zip code:
Contact Person
First name: *
Last name: *
Phone number: *
Please include area code
Email: *
Best time to reach you?

Morning Afternoon Evening Anytime
What is the best way to reach you? *

Email Telephone Either
Do you know someone in our company personally?

No Yes
If yes, Who?
Do you do business with us?

Yes No
If Yes, at which pharmacy?

Harrisburg Pharmacy See-Right Pharmacy Good Day Pharmacy Cumberland Apothecary Pine grove Pharmacy
Have you applied for a donation for your organization in the past?

Yes No
Federal tax exempt 501c public charity?
Requested Amount
Or, request an item donation
What would be good?
Or, tell us how we may help you another way....
Description of need
When/Where will the event take place?
(If Applicable)
When do you need to receive the donation?

Month Day Year
What specific benefits/outcomes will be realized with this donation?
Would you be willing to provide photos or a short note if available regarding the outcome of for use on our social media and to share with our employees?

Yes No
Please verify that you are human *
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm