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!

120 Waterfront Street Suite 420 #2017 National Harbor, MD 20745

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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