MMI Warehouse Pick Up 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?

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?

To:

What type of mission will this be?

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 value 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 value 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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