International Product Request Form

Charitable Organization Name *

Contact Name *

Phone (area code included) *

Email *

Address *

Address Line 2

City *

State *

Zip *

Purpose of Donation *

Where will the Product be used *

Description of Requested Product(s) *

Is the charity or foundation a current or potential customer of DLO? *

Does the charity or foundation have an IRS Regulation 501(c)(3) status? *

Will the requested product(s) be given or loaned to the charitable organization? *

DLO can only ship products to a domestic location. Are you able to arrange for export and use outside of the United States? *

Comments

OKC: 405.608.6100 Tulsa: 918.294.5300 Toll Free: 1.800.891.2917

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The information contained here on the Diagnostic Laboratory of Oklahoma (DLO) website is not to be construed as medical recommendations or professional advice. Neither DLO nor its affiliates, agents or any other party involved in the preparation or publication of the works presented is responsible for any errors or omissions in information from the use of such information. Readers are encouraged to confirm the information contained herein with other reliable sources and to direct any questions concerning personal health care to licensed physicians or other appropriate health care professionals.

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International Product Request Form