Free and Charitable Clinic Application

Free and Charitable Clinic Application

(US-based Clinics Only)
Today's date

MonthDayYear
Date
Name of Clinic / Organization*
Organization Website*
examplesite.org
Contact Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Contact Email*
example@example.com
Clinic / Organization Address*

Street Address

Street Address Line 2

CityState

Zip Code
Which COUNTY is this in?*
Please indicate the Local COUNTY in which your clinic operates. This is important, as we seek grant funding to help offset the costs of acquiring, storing and delivering donated supplies and equipment, and many are county-specific. Thank you!
Are you a member of your state's Free and Charitable Clinic association?

YesNoNot Sure

Please provide the name of the contact person we can reach out to for the detailed Demographic and Financial information.
Name 2*

First NameLast Name
Email 2*
example@example.com
Phone Number 2*
Please enter a valid phone number.
Recipient Agreement
Should be Empty:

General Information