TePe Donation Request Form

Organization & Contact Information
Organization name*
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
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.*
ChildrenAdultsSeniorsDental PatientsDental ProfessionalsOther
If Other, please specify intended audience
Estimated number of individuals to be reached*
Alignment with Prevention & Education
YesNoOther
If oral health education 'Other', please specify
Dental professionalHygienistEducatorOther
If Other, please specify education provider
How will the products be introduced or explained to recipients?*
TePe Values
PreventionPatient complianceOral health educationSustainability / environmentally responsible careCommunity health
YesNoOther
If Other, please specify sustainability practices
Product Usage & Distribution
Please list the products and quantities requested*
Given directly to patientsUsed in demonstrationsIncluded in kitsOther
If Other, please specify product use
YesNo
Event materialsSocial mediaWebsiteOther
If Other, please specify acknowledgement location
YesNo
Timing & Logistics
Requested delivery date*

MonthDayYear
Date
YesNo
If yes, related event date

MonthDayYear
Date
YesNo
YesNo
YesNo
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