Donation Request Form

MINT dentistry and Dr. Field Harrison are proud to support hundreds of worthwhile charitable causes and events each year. We make every effort to accommodate as many requests as possible. However, due to the number of requests MINT receives on a monthly basis, we are simply unable to accommodate all requests that fit our guidelines. We have a standard process we must follow due to the large demand of donation requests we receive. Having a policy in place helps our company manage the many requests for donations that are made by charitable organizations throughout the year.

In order for your organization to be considered for a donation item, you must comply with the following guidelines:

Written or phone requests are not accepted. The online donation form must be filled out completely in order for your request to be considered.
Donation requests must be received at least six (6) weeks prior to the day your organization needs the item contributions.
Your organization must be located in the state of Texas.
Your organization must not have received a donation from MINT dentistry during the current calendar year. An organization is eligible to receive only one donation per year.
Your non-profit organization must have 501(c)(3) Tax-Exempt status. You must enter your organization’s valid Tax Exempt ID number on the donation request form in order for your request to be considered. (If you are a business sponsoring a charitable event, please ask a member of the charity to complete the donation request form.)
Due to the large volume of requests received on a monthly basis, there are no exceptions to the above guidelines. Please keep in mind that submitting an online request does not guarantee your organization will receive a donation. No phone calls, please.

We admire your generous heart and willingness to serve others. This is truly God’s love on full display. Thank you for considering MINT dentistry as a contributor. We wish you the best with your charitable and fundraising efforts. Thank you for all that you do for our community!

Organization Name

Tax ID

Year Established

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Organization Type

Church (Denomination)

Type

CEO, President, Executive Director, or Development Officer at the Organization:

Full Name

First NameLast Name

E-mail

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Website

Requester Contact Information

Full Name

First NameLast Name

E-mail

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Title

Organization's Event Details

Event Name

Description

Event Date

MonthDayYear

Event Location

Number of Guest

Event Sponsor or Underwriter

Request Details

Item(s)

Date needed by

MonthDayYear

Please enter the contact name and email of the person who referred you to submit your request to Mint Dentistry. (Leave blank if no one referred you.):

First NameLast Name

*Please Note: Submission of this request does not guarantee that request will be fulfilled.