donation request form donation request form If you are human, leave this field blank. Organization Name * First Name * Last Name * Email * Phone * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Event Name Event Description Number of Bottles Desired * Bottle Size 8 oz 12 oz 16.9 oz 20 oz Ltr How will the donation be used? (silent auction, fundraiser, handouts, etc.) When would you like to pick up your donation? What recognition will Virginia Artesian receive at your event? At Virginia Artesian, we are committed to and strive to be active members of our community. We ask that you complete your donation request completely, at least two weeks prior to your event. Even with the large number of requests we receive, we do our best to respond to each and every one in the most timely manner. Thank you!