Donate

Cheek and Scott is proud to be a locally owned and operated Community Pharmacy and Medical Equipment provider for our area. We appreciate the opportunities to support our community by considering a contribution to your Organization. Due to the high volume of requests for contributions, we ask that you complete the form below so that we can consider your inquiry.

Full Name *

First Name Last Name

E-mail *

Your title / position at Organization:

Phone Number

Area Code Phone Number

Name of Organization (if funded, the check will be made to this organization): *

Organization is incorporated as a 501(c)(3) non-profit? *

Yes No

Federal Tax ID #:

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Organization's Website:

Organization's Facebook page:

Description of Organization:

Select a category that this Sponsorship / Donation would fall under:

Improving Health and Wellness Supporting K-12 Education Supporting Faith-Based Efforts

Name of Project or Event

Date of Project or Event

Month Day Year Date Picker Icon

Project or Event Description:

Project or Event flyer, brochure, informational sheet, etc. (PDF format preferred):

How many people do you anticipate attending this event?

Which C&S Store does this pertain to?

Live Oak Lake City Jasper ALL

Amount or Item(s) Requested: *

Has Cheek and Scott contributed to your Organization's project or event previously? If so, how much was our contribution before?

Will this contribution primarily benefit low- to moderate-income individuals? If YES, please explain:

Please list all advertising opportunities associated with this project/event which will be available to Cheek and Scott (should we decide to help fund this project/event)

Program Ad Logo placement on banner, shirt, etc. Logo placement on website Booth space Space available for Cheek and Scott banner Photo opportunity with Cheek and Scott staff Other (see below)

Please explain any other advertising and promotional opportunities:

Deadline for advertising opportunity:

Month Day Year Date Picker Icon

Do you and/or your Organization consider Cheek and Scott as their primary pharmacy? If not, what would be instrumental for you to allow us to serve your pharmacy and medical equipment needs?