OTC Product Donation Form

Fill out the form to donate products

A tax receipt will be issued upon receipt. Thank you for your generosity.
General Information
Name*

First NameLast Name
Company Name*
Title (if applicable)
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Donation Information*

	Donation of product (size, style, color)	Price per unit	Total Units	Expiration date (if applicable)
Item
Item
Item

Total value of donation*
Select the formula that most accurate reflects the valuation basis used:*

Retail Sales ValueWholesale Sales ValueManufacturing Cost
Logistics Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address of product location*

Street Address

Street Address Line 2

CityState

Zip Code
Timeline for donation to be shipped*

MonthDayYear
Date
Would you be willing to provide shipping support?*

Yes, donor will arrange and pay for shipping costsYes, Teen Health will ship, and donor will reimburse shipping costsNo
If you would like to provide shipping support, are there any shipping support limitations?
Pallet count*
Truckload count*
How will the product be shipped?*

On PalletsFloor loadedOther
Product Donation Name
Product Name, P1
Price, P1
Amount, P1
Expiration Date, P1
Product Name, P2
Price, P2
Amount, P2
Expiration Date, P2
Product Name, P3
Price, P3
Amount, P3
Expiration Date, P3
Should be Empty:

Fill out the form to donate products