GCS ITEM DONATION FORM

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Fields marked * require an entry.

Please complete one form for each item donated. Thank you!

Item Information

Item Name:*

Estimated Value $:*

Item Description:*

List here additional details such as expiration dates, available dates, delivery plans,...:

I am a(n):*

Individual Donor

Business Donor

I would like to remain anonymous:*

Yes

No

Contact Information

Company:*

First Name:*

Middle Name:

Last Name:*

At least one phone number is required.*

Mobile Phone:

Home Phone:

Email:*

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