Please fill out the following collection barrel request form.

Number of Barrels

(If multiple sites are involved, list addresses in the "Additional Information" area)

Your Name

Company/Institution

Address

City

State
 Zip

Phone

Email

The sign above the barrel can be customized to display your company's name and logo in appreciation of your effort.

Additional Information

How do you wish to make your donation?

 I'm sending you a check now
 I need an invoice for my pledge (Please pay within 30 days)
 Online with a Credit Card/PayPal


Online Donation

Click the Donate button to use a credit card or PayPal.
(Will open in a new window.)
A PayPal account is not required to donate with a credit card. On the payment page, look for Don’t have a PayPal account? and you will see a link to continue without logging in.

iconbarrelrequestformDonation By Mail

Click here to download a PDF that you can print out and mail in along with your donation.

Requires Adobe Acrobat Reader

Allow up to four weeks for barrel shipment. Barrel(s) will be shipped in boxes marked “SAVE for Return Shipment”. (Please remember to save this box.) During the drive we will send you a pre-paid UPS return label that you will use to ship back the barrel in the saved box.

Display the barrel in a conspicuous place at your facility. Vestibules and lobbies are best. Please return the barrel after displaying for a month or when it is full, whichever comes first.

If you have questions or concerns you can call us at (301) 891-2900 or email us at info@securethecall.org.

Thanks for your support!