Domestic Request for Humanitarian Aid

Domestic 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:

First NameLast Name
Alt. Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Alt. Email:
example@example.com
Federal ID Number:
Type of Non-Profit/Tax Exempt Organization?

Other
Please attach IRS Determination Letter or other proof of Tax Exempt Status

Cancelof
Program activities and services provided by your organization, including impact on your target population.
Provide the estimated number of beneficiaries for each category below:
(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(s) 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?
Provide the estimated number of beneficiaries for each category below
Warehouse Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Warehouse Hours:
Do you have a loading dock, forklift and/or pallet jack?
Digital Signature
Title
Should be Empty: