Equipment Request Form

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Facility Name

Name of Contact Person

Email

Facility Website

Are you willing to send pictures of your facility before and after your donation? *

Yes

No

Address

Country

Code

Phone

What equipment or supplies are you requesting?

Thanks! We’ll get in touch soon!

316 F ST. N.E. SUITE 215 WASHINGTON, DC 20002

120 Waterfront Street Suite 420 #2017 National Harbor, MD 20745 (Mailing Address)

The Gbleehai Foundation is a 501c(3) tax exempt organization, IRS section 170(b)(2)(iii) for both federal and state tax purposes.

Tax ID Number: 87-1110968

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