International Request for Humanitarian Aid

International Request for Humanitarian Aid
Organization Name:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Person:*

First NameLast Name
Phone Number*
Fax Number
Email*
example@example.com
Alternate Contact Person

First NameLast Name
Alternate Phone Number
Alternate Email
example@example.com
Registration Number:*
By what Government Agency was your organization registered?*
Place of Registration*
Date of Registration*

MonthDayYear
Date
Proof of Registration and/or Tax Exempt Status:*

Cancelof
Is your organization entitled to receive humanitarian cargo taxes and customs duties free?*

YesNo
Program activities and services provided by your organization, including impact on your target population.*
Enter the number of people in each category below who benefited from the cargo:
(0-17) Children*
(18-64) Adults*
(65+) Seniors*
Give us a short description of the area (city, state, region, country) where your organization is working and your target population.*
Type of humanitarian assistance your organization is requesting?

FoodHealth & HygieneHumanitarian Aid (Clothing, Shoes, Household, etc.)PharmaceuticalsMedical Equipment & SuppliesOther
Description of items requested:*
Please include specific items currently requested and/or items needed on a regular basis
How will your organization distribute the donated cargo?*
Digital Signature*
Should be Empty: