MMI Warehouse Pick Up Request Form

MMI PARTIAL SHIPMENT REQUEST FORM

Name of Organization (required)*
Website
Address of your Organization (required)*
Street Address Address Line 2 City State ZIP Code
Contact Person (required)*
Email (required)*
Phone Number (required)*
Is your organization a registered U.S. non-profit?
- Yes
- No
Is your organization associated with a religious, social, or cultural association? Please explain.
Please give a brief summary of the purpose of your mission project.
What are your travel dates?
MM slash DD slash YYYY
To:
MM slash DD slash YYYY
What type of mission will this be?
- Medical
- Educational/Humanitarian
Will the items be picked up (Fresno, CA) or shipped to your location? If shipping required, enter shipping address below.*
Request Items

For each of the following, please enter the number of items requested in the boxes below.
Band-Aid
Blood pressure cuff (up to 10)
Please enter a number less than or equal to 10.
Dressing 2x2, 3x3, 4x4 clean Sterile/assorted
Dressing, ABD
Glove, exam
Glove, surgical
IV catheter, assorted sizes
Mask, face TB, N95 assorted
Needles, hypodermic, assorted
Skin prep – alcohol pads
Skin prep - chlorhexidine pads
Skin prep-povidone iodine pads/swabs
Stethoscope (up to 10)
Please enter a number less than or equal to 10.
Suture, assorted
Syringe, with needle, assorted ml and needle size
Syringe, luer lock/slip tip 10ml or smaller
Tape, medical assorted sizes/types
Thermometers, digital probe covers
Urinary catheters, foley straight
Other Items requested, but not included in above list.
Item Requested Quantity
What Kind of Animal says "Meow"?*

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MMI PARTIAL SHIPMENT/PICK UP REQUEST FORM

Available to medical mission teams that can hand-carry these items and organization teams not needing a shipping container.

MMI PARTIAL SHIPMENT REQUEST FORM

Request Items

Title

Item	Requested Quantity