Blood Drive Submission Form Oct. - Nov. 2019

WIN a $50 bill credit

Tells us where and when you donated blood and be entered to win a $50 bill credit. Help Paulding Putnam Electric Co-op reach a goal of saving 1000 lives in 2019! Together we can accomplish this goal.

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* 1. What is your contact information?

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Where did you donate?

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* 3. What date was your donation?

Paulding Putnam Electric Co-op will draw a name at the end of each month for those who submit their names. Please make sure to include all of your contact information above. Please enter only once per month. You are eligible to submit each month. Donation needs to have occurred within the 2019 calendar year.