BOL In-Kind Donation Form

.

BRIDGE OF LIFE

In-Kind Donation Form - Equipment

2000 16th St., Denver, CO 80202 | 888-374-8185

www.bridgeoflifeinternational.org

In-Kind Donation Information

Thank you for your interest in making an inkind donation to Bridge of Life. By donating medical equipment or supplies, you’re supporting Bridge of Life to improve health around the world.

Due to limited storage space and the challenges of international shipping, we are not able to accept every inkind donation. All product offers are evaluated based on the specific needs of the health facilities and programs that Bridge of Life supports worldwide. Donated medicine and supplies must have at least 12 months to expiration date at the time of donation. We do NOT accept any liquids.

Please use this form to share more about your inkind donation. Once submitted, someone from the BOL team will contact you ONLY if we are able to accept any or all of the donation items.

Instructions for completing the IN-KIND DONATION FORM:

Provide information related to the donor including name, organization, address, and other contact information.
Provide detailed information related to the description of the item or service being donated.
The Estimated Fair Market Value (FMV) must be completed by the donor. Bridge of Life cannot place a FMV amount or interpret the value of any non-financial donations.
Bridge of Life (BOL) will ONLY contact the donor if we can accept any or all of the donation items.
Should BOL accept the donation, a formal thank-you letter/tax-deductible receipt will be sent to the donor.

Thank you again!

Donor Information

Date*

MonthDayYear

Vendor or Organization Name*

Contact Name*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Area CodePhone Number

E-mail*

Donation Information

Prerequisites: All machines must be in working order, biohazard & chemically free, disinfected, then drained. All cords and hoses secured with IV poles down.

Facility Number*

Equipment Pick-Up Date*

Date

Equipment Pick-Up Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Days of Operation for Pick-Up*

Times of Operation for Pick-Up*

Lift Gate Required?*

YesNo

Any Restrictions on Truck Size Allowance at Facility?*

YesNo

If Yes, Please Describe:

Item/s*

	Equipment Type	Quantity	Serial Number	Hours	Software Version	Rate Condition (Good, Fair, Poor)	Estimated FMV Per Item (USD $)	TOTAL ESTIMATED FMV (USD $)
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8
Item 9
Item 10
Item 11
Item 12
Item 13
Item 14
Item 15
Item 16
Item 17
Item 18
Item 19
Item 20
TOTAL

If you have additional items to list, please upload an Excel spreadsheet with your total list and leave the above table blank. Please format your spreadsheet using the same columns and rows as above.

Upload a File

Comments: