In-Kind Donation

Fields marked * require an entry.

Item Information

Item Name:*

Estimated Value $:*

Item Description:*

Notes:

I am a(n):*

Individual Donor

Business Donor

I would like to remain anonymous:*

Yes

Certificate provided by Beyond Differences or Donor:

Beyond Differences

Donor

How will we receive these items?

Mailing

Pickup

Date & Time for pickup:

Comments & Other Instructions:

Contact Information

Company:*

First Name:*

Middle Name:

Last Name:*

At least one phone number is required.*

Mobile Phone:

Home Phone:

Work Phone:

Email:*