Donation Requests

Product Donation

Please fill out this form in order to be considered for a product donation from Neotech Products.

ATTENTION: This form submission is intended for medical missions and other non-profit projects. If you are interested in requesting product for clinical-based research, please visit neotechresearch.com.

Click here for regular product samples.

Name*
First Last
Email*
Phone*
Organization*
Organization Title/Role*
Organization Website
Is your organization a 501c (non-profit)?*
- Yes
- No
501 C EIN Number
Which state is your organization based in?*
Ship To Address*
Address 2
City & State*
City State / Province / Region
Zip/Postal Code & Country*
ZIP / Postal Code Country
Date donation needed by?*
MM slash DD slash YYYY
Have you received a donation from Neotech in the past?*
- Yes
- No
A Yes answer will not disqualify your application.
If yes, please describe.

Which product(s)? How many units? Etc.
Please give a brief description of your mission or project, and provide any additional details.*
Briefly describe how your project will help support Neotech's overall mission of "Making a Difference."*
Upload proposal or relevant supporting documents (if applicable)
Drop files here or

Accepted file types: pdf, doc, docx, ppt, pptx, key, xls, xlsx, jpg, png, gif, Max. file size: 5 MB, Max. files: 5.
Upload up to 5 files. (pdf, doc, docx, ppt, pptx, key, xls, xlsx, jpg, png, gif)
List requested product(s)*
Include name of product, size, and preferred quantity. Include catalog number, if known. Please be as specific as possible. i.e. N700 NeoBridge Micro: 40 units.
Additional Comments
CAPTCHA

Monetary Donation

Please fill out this form in order to be considered for a monetary donation from Neotech Products.

ATTENTION: This form submission is intended for medical missions, non-profit projects, family support, and event sponsorship. If you are interested in requesting support for clinical-based research, please visit neotechresearch.com.

Name*
First Last
Email*
Phone*
Organization*
Organization Title/Role*
Organization Website
Is your organization a 501c (non-profit)?*
- Yes
- No
501 C EIN Number
Which state is your organization based in?*
Address*
Address 2
City & State*
City State / Province / Region
Zip/Postal Code & Country*
ZIP / Postal Code Country
Have you received a donation from Neotech in the past?*
- Yes
- No
A Yes answer will not disqualify your application.
If yes, please describe.

How much? What was it for? Etc.
Is your donation request amount...*
- Under $250
- Between $250-$1,000
- $1,000-$2,500
- Over $2,500
Please enter the donation amount requested.*
Please give a brief description of the project or event for which you are requesting funds.*
Briefly describe how this donation will help support Neotech's overall mission of "Making a Difference."*
Please select a donation category*
If other, please describe.
Date donation needed by?
MM slash DD slash YYYY
Upload proposal or relevant supporting documents (if applicable)
Drop files here or

Accepted file types: pdf, doc, docx, ppt, pptx, key, xls, xlsx, jpg, png, gif, Max. file size: 5 MB, Max. files: 5.
Upload up to 5 files. (pdf, doc, docx, ppt, pptx, key, xls, xlsx, jpg, png, gif)
Additional Comments
CAPTCHA

Scholarship Application

Please fill out this form in order to be considered for a scholarship from Neotech Products.

ATTENTION: This form submission is intended for Neotech employees, Home Health conference attendees, and other invited applicants in need of financial support.

Shopping Cart

Product Donation

Monetary Donation

Scholarship Application

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