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 us a short background of your mission trip.

What are your travel dates?

To:

What type of mission will this be?

Where will you be traveling?

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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