skip to Main Content
1-914-920-5081 info@afyafoundation.org

LUGGAGE FOR LIFE FORM

Name & Credentials (if it applies-MD, DNP, RN, PA, CNM,)

Date of Request

Date of Travel

Pickup or Delivery ($100 pickup/$125 if delivered by mail)

PickupDelivery

Requested Pickup/Delivery Date

Personal Email Address

Country you are Visiting Abroad

Name of Clinic Abroad

Address of Clinic

Point of Contact at Clinic

Point of Contact Email:

Website (if available)

Shipping Information for Bag Delivery in US (if applicable)

Name

Address

City

State

Zip Code

Upon completion of this document, please attach a list of requested materials including consumable/disposable supplies, single use items, durable medical goods, electrical biomedical equipment & surgical tools.

I understand that submitting this application does not guarantee The Afya Foundation will fulfill on all items requested on this request.  Afya relies on medical supplies donations from partner organizations.  We will strive to include the majority of your requested items in your shipment.

Afya does not ship any pharmaceutical medications.

Digital Signature

Date of Digital Signature

Back To Top