Non-School Application

To request materials for agencies other than schools, please fill out the following online form. You will be contacted once we receive your request. If you are requesting materials for a school, click here.

Name of Organization:
Contact Person:
Address:
 
City
State:
 Zip:
Senator and Rep. District #:
County:
Phone Number:
 Township:
Fax Number:
Email Address:

Materials Requested are for: (required field)

  Family Independence Agency Shelter
Health Department/WIC Homes for the Aged/Group Home
Correctional Facility Other:

Number of individuals in program (required field):

Age 0-5
Age 12-13
Age 6-8
Age 14-18
Age 9-11
Age 19+

 

Please specify reading level or special needs of the individuals you are requesting materials for:
   
Explain how you plan on using the materials:

Do you certify that these materials will be given to individuals for their personal use and not retained by your agency?

Yes | No

Does your facility have a loading dock? Yes | No (NO STAIRS OR ELEVATORS)

Is your organization willing to pick up your free materials in Gregory, Michigan?
Yes | No

Hours deliveries can be received:

"I understand these materials are to be used in compliance with the guidelines attached under 501 (3), 170 (e) (3) rules. No materials will be sold but will be distributed to qualifying individuals."

By selecting submit below, I understand and agree
to abide by these rules.

 

 

If you would prefer, you may also contact us at 800-846-8876 or 734-498-3003 to request the application and guidelines to be faxed or mailed to you.

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