Blessing Application

Case Number

B-12-001118

Please write this case number down and keep it for your records.

Organization Information

Organzation Name	*
Country	*
Street Address	*
City	*
State	*
Postal Code	*
Director's Name	*
Director's Phone	*
Director's Email	*

Primary Contact First Name	*
Primary Contact Last Name	*
Primary Contact Address 1	*
Primary Contact Address 2
Primary Contact City	*
Primary Contact Country	*
Primary Contact State	*
Primary Contact Postal Code	*
Primary Contact Phone	*
Primary Contact Fax
Primary Contact Email	*

Children Information

Number of children in Organization
Number of children who are Critically Ill
Number of children who are undernourished
Number of Caregivers
Is there sufficient staff to distribute products daily?	No Yes

Shipping Information (Optional)

Date of Trip
Number of People Traveling
Luggage Space Available
Name
Address
City
Country
State	*
Postal Code
Phone
Email