TePe Donation Request Form

Organization & Contact Information
Organization name*
Organization Type

Dental PracticeNon-ProfitSchoolPublic Health OrganizationCommunity ProgramOther
If Other, please specify organization type
Website or social media handle
Full name of primary contact*
Title or role with organization*
Email*
example@example.com
Phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Shipping address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Is your organization a current TePe customer or partner?

YesNo
Donation Purpose & Program Details
What is the primary purpose of this donation and how will TePe products support prevention or oral health education in this program?*
Please describe the event, program, or initiative where the products will be used.*
Who is the intended audience?*

ChildrenAdultsSeniorsDental PatientsDental ProfessionalsOther
If Other, please specify intended audience
Estimated number of individuals to be reached*
Alignment with Prevention & Education
Will oral health education or instruction be provided alongside the products?*

YesNoOther
If oral health education 'Other', please specify
If yes, who will provide the education?

Dental professionalHygienistEducatorOther
If Other, please specify education provider
How will the products be introduced or explained to recipients?*
TePe Values
Does your initiative emphasize any of the following?

PreventionPatient complianceOral health educationSustainability / environmentally responsible careCommunity health
Are sustainability or environmentally conscious practices part of your program or organization?

YesNoOther
If Other, please specify sustainability practices
Product Usage & Distribution
Please list the products and quantities requested*
How will the donated products be used? (Donations are not provided for distribution or resale use.)*

Given directly to patientsUsed in demonstrationsIncluded in kitsOther
If Other, please specify product use
Will TePe be acknowledged as a donor?

YesNo
If yes, where will TePe be acknowledged?

Event materialsSocial mediaWebsiteOther
If Other, please specify acknowledgement location
Are photos or testimonials available for TePe to utilize after the program/event?

YesNo
Timing & Logistics
Requested delivery date*

MonthDayYear
Date
Is this request tied to a specific event date?

YesNo
If yes, related event date

MonthDayYear
Date
Is partial fulfillment acceptable?

YesNo
Have you previously received donations from TePe?

YesNo
Do you acknowledge that donation approval is discretionary and subject to review?*

YesNo
Do you agree not to resell donated products? (TePe does not authorize or approve resale of donated products.)*

YesNo
Anything else you want us to know about your donation request?
Should be Empty:

Organization & Contact Information

Donation Purpose & Program Details

Alignment with Prevention & Education

TePe Values

Product Usage & Distribution

Timing & Logistics