Mission Request Form - Kingsway Charities Inc., Bristol, VA

                      KINGSWAY CHARITIES INC. INTERNATIONAL
                                                        1119 Commonwealth Ave. Bristol VA 24201
                                               Toll Free Phone: 800-321-9234   Phone: 276-466-3014

MISSION SUPPLY REQUEST FORM

PLEASE FILL IN ALL REQUIRED INFORMATION (*):

NOTE: We require at least 8 weeks notification from receipt of this form in order to ship your product on time.

Missionary or Team Leader *

Address:* (All correspondence for this trip will be mailed to this address)

City:*	State:* Zip/Postal Code:*

Phone: * Fax: Email Address:*

Sponsoring Ministry:* Email Address: * (Sponsor)

Contact Person:* Contact Phone: * Contact Fax:

Contact Address:*

City: State: Zip/Postal Code:

Physician on trip or at destination:*

Date(s) of Mission: Leave: * Return:

If repacking earlier, Packing Date:

Country of Mission: * City/Province of Mission:

Statement of Evangelism Activities:*

SHIPPING INSTRUCTIONS: Please give us the physical address for package delivery and the phone number

Name:* Phone:*

Address:*

City:* State:* Zip/Postal Code:*

What is the maximum weight of medicine you can receive? lbs.*

NOTE: Please be aware that we may not be able to send the full amount requested, but we will not exceed your maximum weight

Comments:

After you are finished, click the Submit button at the bottom of the form to send the information.