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Will you be a "link" in our supply chain of healing and hope? Learn more about CrossLink's Adopt-A-Mission program. 
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CFC Code#:14672 |
United Way Code #: 8295 |
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| Breaking News |
2008 Band Aid Ball On-Line Registration The Asian Allure Band Aid Ball Saturday, May 3, 2008 Auction Items Sneak Peak! Room Reservations! Discounted Rate Cut off April 18th! |
Will you help? Your $25 gift to CrossLink will provide a blood pressure cuff, a stethoscope and a thermometer for a doctor working in a developing country.  |
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| Faxable Project Request Form | |||
| To request a project from CrossLink, please complete and submit this form to begin the evaluation process | |||
| Before submitting your request, please read the Requirements to determine if your project is consistent with CrossLink's mission. | |||
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| General Information | |||
| Fields marked with an * are required! | |||
| Date of Request: | |||
| *Requesting Organization: | |||
| *Name of Contact: | |||
| *Relationship to Trip: | |||
| *Email: | Web Site: | ||
| *Phone: | Fax: |
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| 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? |
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| *Country/location where items will be used (include name/address of facility/location where items will be used) |
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| 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: |
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| USA | |||
| In-country | |||
| *Is there a hospital or clinic at the site for follow-up care? Yes No | |||
| *Is there a physician/LNP on team or in-country who can diagnose/prescribe meds? Yes No |
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| 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) | |||
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 |