Meritus Health In-kind donation form

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* 1. Please describe the item: Please include any applicable expiration date, restrictions, and special instructions.

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* 2. What is the approximate value?

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* 3. Would you like to remain anonymous?

Yes

No

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* 4. Please Provide Donor Contact Information

Name

Company (if applicable)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 5. Is this item a gift certificate?

Yes

No

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* 6. Will this item be dropped off?

Yes

No, but it can be made available for pickup

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* 7. Collection Details: Please specify any special delivery/pickup details, including preferred pickup date/time.

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* 8. Is this item being donated on behalf of a business?

Yes

No

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* 9. If you have additional questions or comments please enter the details below or contact the Meritus Healthcare Foundation at 301-790-8631, or foundation@meritushealth.com.