Technology Equipment Donation Request

Name of Organization:*

Business Address of your organization:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address of your organization (if different than business address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Requestor Name:*

First NameLast Name

Requestor Title:*

Requestor Phone Number:*

Please enter a valid phone number.

Requestor E-mail address:*

example@example.com

What is your organization's mission and vision?*

Which of the community priorities does your organization or a program you offer address?*

Lack of access to careIncreasing cost of housing and homelessnessLack of access to mental health servicesLack of access to fresh, healthy food and food insecurityNone of these

Please briefly explain how your organization or program you offer addresses one (or more) of the community priorities:*

How will this donation enhance effectiveness and/or efficiency?*

Which of the 5 Northeast Florida Counties do you serve? (check all that apply)*

How do you serve the county you selected above?*

Where will this equipment be located?*

What type of equipment are you looking for?

How many desktop computers are you requesting?*

How many monitors are you requesting?*

How many laptop computers are you requesting?*

How many tablets are you requesting?*

How many desktop printers are you requesting?*

How many keyboards are you requesting?*

How many mice are you requesting?*

How many iPhones are you requesting?*

How many document scanners are you requesting?*

How many barcode scanners are you requesting?*

Donation Acceptance Agreement

By signing, you acknowledge you have read and accept the terms and conditions of this Agreement in its entirety. In addition, you represent and warrant that you are authorized to enter into this agreement on the organization’s behalf.

Your organization must not sell, trade, barter, or otherwise transfer any donated goods in exchange for money, property, or services. Prohibited transfers include listing the donated goods for sale or trade on websites, in stores, at flea markets, or in any similar manner.
Your organization must not use donated goods for raffles, auctions, or any fundraising activity.
Your organization must not accept anything of value (including voluntary donations) in exchange for the donated goods.
Your organization must not give any donated goods to its volunteers, officers, directors, employees, or contractors for personal use.
Your organization must not return any donated goods to the manufacturer or to any retail store.
Your organization must not give donations to another nonprofit organization or other entity.
Your organization must not redistribute any donated goods to any location outside of the United States.

Name of CEO or Executive Director:*

First NameLast Name

Phone Number of CEO or Executive Director: *

Please enter a valid phone number.

Email of CEO or Executive Director:*

example@example.com

CEO or Executive Director Electronic Signature:*

Please upload your organization's W-9:*

Please upload your organizations's 501(c)(3) designation letter:*