Donations

Village Dermatology is committed to helping non-profit organizations. Each week we receive many requests for donations. To be considered, please fill out this form and submit. We will get back in touch with you soon. We are happy to consider your request!

Company or Organization(Required)

Date Submitted(Required)

Contact Person(Required)

First Last

Contact Cell(Required)

Business Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Tax ID Number

Name of Event(Required)

Date of Event(Required)

What date do you need to pick it up?(Required)

Location of Event(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Would your organization be willing to post our logo on your website and/or display Village Dermatology’s marketing materials at the event?(Required)

Yes

Upload any files here

Max. file size: 2 MB.

Name

This field is for validation purposes and should be left unchanged.