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?
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?

Other
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: