Dine and Donate Form

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Country *

Organization Type *

State/Province

Please fill out any missing organization information below.

Organization Name *

Tax ID If you know the Tax ID it will speed up the processing and verification of your request.

Alternate Name *

Is there a different name, DBA or chapter?

Year Established

National Taxonomy of Exempt Entities (NTEE) Code *

Mission Statement *

Org Contact First Name *

Last Name *

Title with the Organization *

Organization Address *

City *

State/Province *

Zip/Postal Code *

Primary Organization Email *

Primary Organization Phone *

Website *

Principal Individuals and Board Members *

The person completing this form who wishes to receive email updates should be entered here

Prefix *

First Name *

Last Name *

Email Address *

Primary Phone *

Cell/Other Phone

Title/Relationship to Organization *

Shipping Options

Address to where donation should be mailed (If possible, please provide a commercial mailing address)

Address Type

Address *

City *

State/Province *

Zip/Postal Code *

Country *

Attachment (optional): Add any additional files that may be helpful for this request

Please attach the following documents:
Certified 501(c)(3) document (Not Tax-Exempt form)

• Documents that describe your event or organization, or other related document.

• (Click on Browse button to attach multiple documents. Files will be uploaded when you click submit. A maximum of three attachments will be saved. Attachments must be in one (1) of the following formats: Pdf, doc, docx, xls, xlsx. Limit the file size to less than 4MB.)
for example Event flyer if nothing specified (Click on Upload File button to attach multiple documents. The files should be selected from a folder on your computer. The files will be listed under the attachment box. Files will be uploaded when you click submit. Attachments must be in one (1) of the following formats: Pdf, doc, docx, xls, xlsx. Limit the file size to less than 10MB.)

Comments

I confirm that I am 18 years or older

* Denotes required fields

This form will expire after 2 hours.

A DonationXchange account will be created and provided in the confirmation email for tracking purposes.

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Dine and Donate Form

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