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Item Donation Page

Item Information

Item Name:*

Estimated Value $:*

Item Description:*

Notes:

I am a(n):*

Individual Donor

Business Donor

I would like to remain anonymous:*

Yes

No

Restrictions and Expiration Date:*

Check one of these boxes:

Donor to mail or deliver gift certificate or item to PROVAIL

PROVAIL has permission to create a gift certificate for this item

Donor would like PROVAIL to pick up gift certificate or item

Donor name (if different than the person filling out this form):

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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