In-Kind Contribution Form
I
f you, your company, or your organization is interested in providing an in-kind donation to the Moore Free Care Clinic please contact our office at (910) 947-6550, and use this on-line form to notify us via email. Fields with an "*" are required.
Contact name*:
Social Security Number or EIN*:
Telephone:
(
)
-
Email Address*:
Company name:
Address:
City:
State:
Zip Code:
Fax:
(
)
-
Company Web site:
Please specifically describe the service or product that you wish to offer.
Please mark the appropriate description(s) of your contribution (check all that apply):
Discount Program
Product
Limited
National
Free
Service
Long term
Regional
Please provide a brief description of your company or organization:
What is your primary reason for wanting to work with the Moore Free Care Clinic?
Please list any free clinics that you have worked with in the past.
Site Map & Credits
