Request Supplies

To request supplies from AMM, fill out the form on this page, download the PDF, or call the office. Your organization can expect to hear from AMM within 1-2 weeks. Following verification of your organization, AMM will fulfill the request to the fullest extent possible.

AMM is proud to donate all the supplies and equipment to your cause free of charge; however, the receiving organization is responsible for the supplies including any related shipping costs once they leave the AMM warehouse.

PDF Request Form

Online Request Form

Please scroll through the form and answer all applicable questions. Fields marked with an * are required.

Name of Organization

Name

First Name

Last Name

Contact Title/Position

Phone

Country

(###)

###

####

Website

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

ABOUT YOUR ORGANIZATION

1. Do you/your organization have a religious affiliation? (Not required to receive donations)

Select

If yes please identify

2. Is your organization registered as a US 501 (c)(3) tax-exempt organization?

3. How long have you been organizing mission trips/managing in-country programs?

4. For SHORT TERM trips only; how often do you schedule medical trips?

Frequency of trips

Please Provide Two Contact References

1. First & Last Name, Organization, phone, email

2. First & Last Name, Organization, phone, email

Facility or Organization Contact Information

Name and contact information of the facility or organization which will be the recipient of donation.

Organization Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Website

http://

Donation Details

Please indicate the program(s) in which the donations will be used.

Please provide an itemized list of the products needed including medical supplies, equipment, and hygiene items.

Required*

In order to receive a donation of AMM medicines and medical supplies you must acknowledge your agreement to comply with the following terms and conditions by reading each statement and signing your initials in the space provided.

Name

First Name

Last Name

Position

Signature

Date

YYYY

Read and Check The Following.

I will insure that all AMM medicines and medical supplies donated to me/my organization will be distributed free of charge and without discrimination of any nature, including race, religion, gender, politics, nationality or geographic location and geographic location.

If a modest administrative fee for service is charged by my organization or the medical facility where services are performed, I will insure that this fee is not identified with the AMM medicines or supplies provided.

I will not return any donation to the United States.

I will not sell or exchange any donation for property or services.

I will provide AMM with narrative feedback, including photographs, reports, distribution grids, or program evaluations for each shipment received.

Most recipients of products provided by AMM pick them up from our staging facility in Anchorage, Alaska. AMM does not normally provide shipping. However, arrangements can be made for this service with all costs associated with such service and AMM related administrative expenses to be paid for by the applicant. These arrangements are to be made additionally and separately from this application process with the staff of AMM.

Date product is requested for pick up at our staging facility in Anchorage, Alaska.

AMM provides an itemized list of donated products and a letter of donation for each shipment. Does AMM need to provide any other documents to ensure delivery of medicines into the country?

Yes

Please Specify

Testimonial

“I am back from the medical mission and I must say this is the most successful medical mission we have had thus far. This is due to the fact that we had critically needed point of care testing machines and other equally important equipment at our disposal thanks to Alaska Medical Mission’s generous donation of equipment. It was heart warning weighing our first infant on an infant scale, prior to your donation, we did not have this very important equipment that helps guide our medication management of our infant patients.”

— Sierra Leone

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