Domestic Confirmation of Receipt

Domestic Confirmation of Receipt

Humanitarian Aid Shipment
Organization Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Bill of Lading/Reference #:*
Please upload Bill of Lading or Proof of Receipt*

If you are unable to provide the BOL or proof of receipt, please upload a document with explanation
Cancelof
I hereby confirm that we have received enter quantity of donated cargo description. This shipment was received on Date in the city of enter city name and state of enter state name.
I hereby confirm that we have received the donated cargo as listed in the associated packing list with the exception of any discrepancies noted below.
Qty Received*
Unit of Measure*
Cargo Description*
Shipment Received Date*

MonthDayYear
Date
City of Receipt*
State of Receipt*
Any damages or discrepancies?*

YesNo
List any items damaged or any discrepancies*
Digital Signature*
Title*
Email*
example@example.com
Should be Empty: