2015 Auction Donation Form

If you have any questions, please contact Kathryn Kovacs at 703-979-1425, ext. 143 or kkovacs@arlingtonfreeclinic.org.

If you would like to make a financial donation in lieu of an in-kind auction donation, you can do so here. Thank you for your support!

Donor Information
Donor Name*
(As it will appear in the auction catalog and/or on the website.)
- Please check here if you do not wish to have your name listed on the AFC website.
Contact Name
(Who should we contact regarding this auction item?)
First Last
Contact Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Email*
Contact Phone*
Would you like to receive an invitation to Arlington Free Clinic's Benefit Gala?*
- Yes
- No
Donated Item Information
Detailed Item Information*
It is important that you include any restrictions and details we can use in marketing materials.
Fair Market Value*
How would you prefer to deliver your donation?*
Items can be mailed or dropped off at Arlington Free Clinic, 2921 11th Street South, Arlington, VA 22204. An AFC Auction Committee/Staff member will be in touch to confirm item delivery or pickup.
- I'll mail it to AFC.
- I'll drop it off at AFC.
- Please pick it up from me.
Please upload your logo here. It will be used on our online auction site. Thank you!
Accepted file types: jpg, png, pdf, eps, Max. file size: 50 MB.
Thank you for supporting medical care for the uninsured!
Your donation may be tax deductible. Please check with your tax advisor. Arlington Free Clinic Tax ID: 54-1671883

Donor Information