Auction Item Donation Form
ADHA Institute for Oral Health Benefit/President's Reception
100%
Questions marked with an * are required Exit Survey
 
 

Please complete this form and then send your auction item to:

ADHA Institute for Oral Health
Attention: Auction Item
444 N. Michigan Ave., Suite 3400
Chicago, IL 60611
Send no later than May 14, 2014
 
 
 
ITEM NAME: (5 words or less) *
   
 
 
 
ITEM DESCRIPTION (35 words): *
   
 
 
 
Item Fits Best into the Following Category:
 
Handbag
 
Jewelry
 
Show Tickets
 
Trip/Travel Related
 
Restaurant/Dining Experience
 
Gift Baskets
 
Other
    
 
 
 
RETAIL VALUE: *
   
 
 
 
BIDDING PRICE: *
 
I would like to set the opening bid (Should be less than the Retail Value)
 
I would like Institute Staff to set the opening bid
 
 
 
Please indicate how we will receive your item: *
 
I have/will ship my auction item to the IOH/ADHA headquarter office before May 14, 2014
 
I will drop of the auction item onsite to the Staff Office, in the Salerno room of Caesar's Palace in Las Vegas, NV
 
 
Auction Item Donated by: (The person/organization indicated below will receive a tax letter for and be thanked in the Donor Honor Roll)
Donor First Name *  : 
Donor Last Name *  : 
Organization *  : 
Address     : 
City *  : 
    State *     Zip *
Phone *  : 
Email Address *  : 
 
 
We will e-mail a confirmation when we have received your item in our office. We will contact you if there are any questions or issues related to your Auction Item.
 
 
 
The information provided above for the auction item description and donor information is correct and accurate.
 
 
Electronic Signature:
   
 
 
Date:
 
 
 
IMPORTANT: WHEN YOU SEND YOUR ITEM IN, INCLUDE A NOTE WITH THE EXACT ITEM NAME YOU ENTERED ABOVE AND THE DONOR'S NAME SO WE CAN CORRECTLY IDENTIFY EACH AUCTION ITEM AND PROPERLY ACKNOWLEDGE THE DONOR.