CrossLink International

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CFC Code#:14672

United Way
Code #: 8295

Faxable Project Request Form

To request a project from CrossLink, please complete and submit this form to begin the evaluation process

Note: This page has been designed for use with Windows
Internet Explorer 7 or below. If you are using a MAC or another browser and do not get an immediate email response or encounter technical difficulties, please contact melinda@crosslinkinternational.net to verify receipt of your request or print a hard copy and fax to 703.536.8349 or mail to 427 N. Maple Ave., Falls Church, Va 22046.

Before submitting your request, please read the Requirements to determine if your project is consistent with CrossLink's mission.

*I accept:

General Information

*Fields marked with an are required!**

Date of Request:
*Requesting Organization:
*Name of Contact:
*Relationship to Trip:
*Email:
Web Site:
*Phone:		Fax:
How did you first hear about CrossLink International?


Billing Address
*Street:		Suite:
*City:		*State:
*ZIP:		*Country:
*Phone:		Fax:
*Email:		ATTN:

I will pick up		Date you'd like to pick up items:
Please ship		Date you need to receive items:

Shipping Address (cannot be a P.O. Box):
Check if Shipping Address is the same as Billing Address:

Street:		Suite:
City:		State:
ZIP:		Country:
Phone:		Fax:
Email:		ATTN:

Please check one of the following:
The address above isResidential Business

Project Information

How does your mission trip reflect the mission statement of CrossLink International?


*Country/location where items will be used (include name/address of facility/location where items will be used)


Project Start Date:
Project End Date:

Number of people to be served:

Number of Team Members:

Brief Project Summary


Most prevalent health problems in the area being served


Who are the people/groups benefiting?


*Name of the organization/physician that will manage the receipt and distribution of medicines, medical supplies/equipment:
USA
In-country

*Is there a hospital or clinic at the site for follow-up care? Yes No

*Is there a physician/LNP on your team? Yes No

Is there a physician/LNP in-country who can diagnose/prescribe meds? Yes No*

We are interested in:
	Purchased Medicines: (approx. budget)
	Purchased Supplies: (approx. budget)
	Donated Medicines (limited quantities):
	Medical Supplies (limited quantities):
	Medical Equipment(requires extra funds for shipping via container or other means):
	Glasses (6 to 8 week advance notice)
	Focometer ($500 deposit required)

  CrossLink International
  Main Office   • 427 North Maple Avenue   • Falls Church, VA 22046 • (703) 534-5465
  Memphis Office   • 200 East Parkway North   • Memphis, TN 38112 • (901) 323-8477