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Fill with sample data
Step 1 of 5
Company website (leave blank)
Step 1 of 4
DaVita Location
Location ID
*
Enter your DaVita Location ID.
Location name
*
Enter the clinic name.
Clinic street address
*
Enter the clinic street address.
City
*
Enter the clinic city.
State
*
Select…
Select the state.
ZIP
*
5-digit ZIP.
Submitted by
Name
*
Enter the submitter's name.
Email
(email or phone)
Enter a valid email.
Phone
(email or phone)
Enter a valid 10-digit US phone number.
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Step 2 of 4
Pick-up Details
First name
*
Enter your first name.
Last name
*
Enter your last name.
Email
*
Enter a valid email.
Phone
*
Enter a valid 10-digit US phone number.
Street address
*
Enter your street address.
Apt / Suite
City
*
Enter your city.
State
*
Select…
Select your state.
ZIP
*
5-digit ZIP.
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Step 3 of 4
Donation details
Product type and count
Fill in how many of each you have. Leave a cell at 0 if you don't have any.
Enter at least one product quantity (max 99 per cell).
Where are the boxes?
*
Inside the home
Driver will need to come in
Outside, easy access
Porch, garage, driveway
Choose where the boxes are located.
Pickup window — earliest
*
Pick a date within the next 60 days.
Pickup window — latest
*
Latest must be on or after earliest, within 60 days.
Preferred time of day
*
Morning
8am – 12pm
Afternoon
12pm – 5pm
No preference
Flexible
Choose a preferred time.
Special instructions
(optional)
0
/ 500
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Step 4 of 4
Review & submit
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Submit
Submitting your request…
Dev preview
Reference number
JOB-—
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