Product Donation Request Form - Nabuur

Product Donation Request Form
Page 1 of 2
Market Code: WEB
Gifts In Kind Registration #______________________
Mandatory for charities registered with Gifts In Kind
Registered Charity Address
Legal Name of Registered Charity
_____________________________________
Street Address
_____________________________________
City/State/Postal Code/Country
_____________________________________
Contact Person
_____________________________________
Telephone
Fax
_____________________________________
E-mail
_____________________________________
Ship To Address
Legal Name of Organization
_____________________________________
Street Address (Cannot be delivered to a P.O. Box)
_____________________________________
City/State/Postal Code/Country
_____________________________________
Contact Person
_____________________________________
Telephone
Fax
_____________________________________
E-mail
_____________________________________
Note: When filling out this section be sure that the item description and item number match the products you wish to receive. If you are ordering more than five items,
photocopy this form to accommodate your request.
Unit of Measure
Admin # of People
Item Description Item #
Quantity Requested
Fee Served
Subtotal:
Add 20 percent additional for shipments to Alaska, Hawaii, Puerto Rico and Virgin Islands. For International shipments, see Page 2 for additional
instructions.
If you are a nonprofit 501(c)(3) organization or U.S. Indian Reservation (with annual revenue less than $1million) and are not currently registered
with Gifts In Kind International, please add $150 to cover registration through December 31, 2006. If your annual revenue is more than $1million,
your registration fee is $300. Please include a copy of your organization’s 501(c)(3) tax determination letter, mission statement, list of board of
directors, and your most recent audited financial statement or 990 Form.
Total:
Please complete the following questions:
How many individuals will you serve this year
_______________________________________________________________________________________________________________________________________
2. What is your organization’s mission
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
3. Please describe how the donation will be used and the impact it will make on people’s lives:
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Please check (select only one) your nonprofit’s main area of focus:
□ Economic Education
□ Cancer Prevention, Screening and Treatment
□ Housing and Emergency Relief Shelters
□ Emergency Relief
□ Other (two-word description)
Please Note: If you are requesting any Gillette, Braun or Oral-B products…
Request limitations:
►Organizations may request up to three pallets per quarter of any of the products that Gillette contributes. This completed application must detail the purpose for which
the contribution will be used, and the timeframe in which distribution will be undertaken. Donations received by the requesting organization cannot be shipped or
distributed outside of the United States.
Revised: 2/14/2006

Product Donation Request Form
Page 2 of 2
Market Code: WEB
For other non-Gillette, Braun or Oral-B products: If you are requesting a full truckload shipment, indicate the number of individuals you expect to serve with
the donations you receive: ________________
If any part of your requested donation will be distributed internationally, check here: and fill out the international section on page 2 of this form.
International affiliates should leave the administrative fee column blank; a determination on fees will be made after the order is received.
Please fill in your payment information below (US and Canadian orders only)
CHARGE MasterCard Visa American Express Discover/Novus
Card Number: ________________________________________ Expiration Date: ________
Name as it appears on card: ________________________ Authorized Signature______________________________
Zip/Postal _______________ Total Fee for this Request: ____________ Billing Code: ________________
GIFTS IN KIND INTERNATIONAL CREDIT VOUCHER (attach voucher)
WIRE TRANSFER
CHECK ENCLOSED— Check Number: ___________________________
Note: The below section must be read and signed by an authorized representative of the requesting organization.
I have read and accepted the terms and conditions as outlined on Gifts In Kind International’s Web site, located at
http://www.giftsinkind.org/terms.asp for the products I have requested.
Yes, I agree to the terms and conditions.
______________________________________ _________________________________ ____________
Print the name of your nonprofit’s Executive Executive’s Signature Date
For all international shipments additionally read and sign the following:
If your organization is located in the United States you must be given written approval by the Gifts In Kind International Network Registration Services to
ship products outside of the United States. Published administrative fees cover shipping to the designated U.S. port of exit. Any costs associated with moving
the product beyond the U.S. port of exit (ocean transport, customs, import, duties, taxes, etc.) will vary according to the ultimate destination and the
availability of free or discounted transportation. International affiliates should leave the administrative fee column blank; a determination on fees will be
made after the order is received. Please note that we will take advantage of every opportunity to reduce costs to keep the total fee for international shipments
as low as possible.
Required Information
1. Attach a detailed plan that outlines how the products requested will be distributed. Include in the plan contact information for recipient, details on
distribution, and a description on how the donation will be protected from theft and misuse.
2. Indicate when the donation must arrive in the country. ______________________________________
3. Which is the best port of entry to use _______________ Alternate ___________________________
4. If you have a transportation company providing free transportation, indicate the type of service available and contact name and phone number to contact
for more information. ____________________________________
5. When the donated products arrive and are distributed, forward to Gifts In Kind International a copy of documentation verifying that all products were
received in good condition.
6. When the donated products have been distributed to the ultimate recipients, provide Gifts In Kind International a report detailing to whom the product
was distributed and the impact the donation is expected to have on the recipient. Include photographs if possible.
Signature of Executive: _______________________________________ Date: ________________
Print Name: _______________________________ Print Title: _____________________________
For deliveries in the United States, allow a minimum of three weeks from the time you place your request until your donation is received. Individual
nonprofits can only use donated products in direct support of their local mission. Network affiliates can only distribute products to support their local
community programs and agencies. Prior written approval from Gifts In Kind International is required before any donated products can be shipped
outside of the United States.
The customer service representative who helped me with this request (if applicable): Lena Sandra Rick Ruthann Miesha
Complete the entire Product Donation Request Form and send to: Gifts In Kind International, P.O. Box 18002, Merrifield, VA
22118. Faxed requests with credit card payment may be sent to 877-798-3192.
Revised: 2/14/2006