Local Donation Request Form

Charitable Organization Name *

Contact Name *

Phone (area code included) *

Email *

Address *

Address Line 2

City *

State *

Zip *

What is the purpose of the event or campaign? *

What would you like DLO to contribute? (Money, Goods, Services, etc.) *

If the request is for Goods or Services, describe the requested product(s)

Is the charity or foundation a current or potential customer of DLO? *

Does the charity or foundation have an IRS Regulation 501(c)(3) status? *

Have you sought contributions broadly from the community for the campaign/event? *

Comments

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The information contained here on the Diagnostic Laboratory of Oklahoma (DLO) website is not to be construed as medical recommendations or professional advice. Neither DLO nor its affiliates, agents or any other party involved in the preparation or publication of the works presented is responsible for any errors or omissions in information from the use of such information. Readers are encouraged to confirm the information contained herein with other reliable sources and to direct any questions concerning personal health care to licensed physicians or other appropriate health care professionals.

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Local Donation Request Form