Supplies Request Form- Community Care

This Form is for Organizations/Churches/Community Service Centers requesting community supplies from the Lithia Dealership Drives

Complete the required fields and share your responses with us.

Full Name (Main Contact) *

Email address *

Organization Name

Address for Delivery

Day/Time you can receive supplies

Phone number to confirm delivery details *

Will these resources serve FIRE VICTIMS solely? *

Yes, with confirmed tracking and reports available. (Preferred)

Yes, without tracking or reports

Varied group served of fire and non-fire victims (you will be placed on waitlist until further notice)

List Items and Quantities Requested, be as specific as you are able.

Describe the demographic of who you serve (ie. school age children, veterans, elderly, etc) *

Please confirm that you are not a robot.

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