C R E C E R invites you to complete and forward this

Request to Donate Equipment Form

		
           Date of Request(mm-dd-yy):  		
Organization Name and Contact Person:  		
                             Address:  
               City, State, Zip Code:  		
                              County:  
                         Postal Code:  		
                               Phone:  
                                 Fax:  		
                              E-Mail:  
                   Tax Exempt? (Y/N):   YES	  NO
           Taxpayer ID/Exempt Number:  
  

Please include a narrative in the space below which answers the following questions:

1. Please describe the equipment including quantity, brand, serial no., description, state of repair, etc.
2. What can the equipment be used to do?
3. If you need approval or concurrence to donate equipment, have you received it?
4. How did you hear about CRECER?
5. As a donor of equipment, will your organization allow CRECER to use
your organization's name in CRECER's publicity and promotional materials?

By submitting my e-mail address, I hereby certify that all information submitted is true and correct. I understand that equipment will not be sold, traded, or bartered. I affirm that I am the owner, or designee, of listed equipment. I understand that CRECER makes no guarantees regarding the equipment, provides no warranties, and has no responsibility for any damages created by this equipment.
I AGREE I DO NOT AGREE