Parent Company Name
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Building or Program Name
*
Contact Name
*
First Name
Last Name
Contact Title
*
Direct Work Number
*
(###)
###
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Cell Phone Number
(###)
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Company Main Number
*
(###)
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Which number is the best to reach you at?
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Direct Work Number
Cell Phone Number
Company Main Number
Work Email
*
Work Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
My organization is a
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What category best describes your organization?
*
Please select all that apply.
If other, please share below:
County or Counties Served
*
Please select all that apply.
If other, please list any additional counties.
Estimated number of seniors currently served at your location:
*
Estimated average age?
*
Our organization is currently serving people from these communities:
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Please select all that apply
other African communities -
other Asian communities -
If you serve additional communities not listed above, please list them below:
How will gifts be distributed?
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If other, please share your procedure below:
As an agency partner of Gifts for Seniors, I am happy to provide one or more of the following:
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Please send attachments to coordinator@giftsforseniors.org.
I follow Gifts for Seniors on Facebook
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Please provide any additional information you wish for us to know about your group:
I certify that all gifts and community resources received from Gifts for Seniors will go to isolated older adults in need.
*
