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Item Donation Form

Item Information

Item Name:*

Estimated Value $:*

Item Description:*

Please indicate if item needs to be picked up or will be mailed. If mailing, please send to Keiro Northwest c/o Karlee Hicks at 700 - 6th Ave S, Seattle, WA 98104:

I am a(n):*

Individual Donor

Business Donor

I would like to remain anonymous:*

Yes

No

Contact Information

Company:*

First Name:*

Middle Name:

Last Name:*

Address:*

Address2:

City:*

State:*

Postal Code:*

Country:*

At least one phone number is required.*

Mobile Phone:

Work Phone:

Email:*