Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Name *

First Name

Last Name

Phone *

(###)

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Is this a non-profit organization? *

If yes, please enter your nine digit federal Employer Identification Number in the field below.

Yes

No

When do you need the donation? *

Donation requests must be submitted a minimum of two weeks in advance.

MM

DD

YYYY

What kind of donation are you seeking? *

$30 Gift Card

Other (please complete the field below)

I understand that donation preferences are given to registered non-profit organizations in the communities most commonly served by Medford Food Co-op; priority is given to organizations promoting local, organic food, food related issues, or community health concerns; and that individuals, commercial enterprises, and partisan organizations are not eligible for donations.