CANUS FOR A CURE DONATION REQUEST FORM
(*) = Required Field
Please fill out the information below for us to consider your request
Organization Name: (*)
Please enter your organization's name!
Organization Address: (Street, City, Zip) (*)
Please enter your organization's address!
Web Address:
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Contact Name: (*)
Please enter your contact's name!
Direct Telephone:
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Fax:
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Email Address: (*)
Please enter a correct email address!
Event Name: (*)
Please enter your event name!
Date of Event: (*)
Please enter your event's date!
Location of Event: (*)
Please enter your event's location!
# of People Attending: (*)
Please enter the number of people attending your event!
Event Type: Please choose one (*)

Please choose your Event Type
Other Cancer-related Cause or Event Type (please describe):
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How will this donation benefit your organization/event?
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Has your organization received donations from Canus in the past? (*)
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If you replied, "Yes" to the above question, for what Event name?
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Type of Product Requested: (*)

Please choose a donation type!
Product Quantity (How much do you need?) (*)
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Is your organization a 501C-3?
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Please fax non-profit status certificate to Robin at Canus VT, 802-244-7343
Ship To Address: (no PO Boxes allowed. Please note we can only ship to business addresses). Please indicate any special shipping instructions:
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Can this address accept pallet deliveries: (*)
Please tell us if you can accept palette deliveries
If No, please provide an additional business "Ship To" address that has a loading dock and can accept a pallet
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Date needed to arrive by: (*)
Please enter a date
Additional Event Information:
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Canus will review all requests and notify you of our decision. If you have any questions or concerns, please contact Lisa Lazarczyk at 781-646-0667 or lisa@lazpr.com. THANK YOU!
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