Equipment Donation

🩺 BarnMD Equipment Donation Form

Supporting Access to Quality Health and Medical Support Services
🌐 www.BarnMD.org
📧 [email protected]

🧾 Donor Information

Full Name / Organization Name: Contact Person (if Organization): Phone Number: Email Address: Mailing Address: City: State/Province: Zip Code:

🏥 Equipment Details

Equipment Name: Quantity: Condition (New/Used): Description / Model: Estimated Value (₦ / $): Total Estimated Value (₦ / $):

🚚 Pick-up or Drop-off

I will drop off the equipment
I request BarnMD to arrange pickup Preferred Date & Time: Pick-Up Address (if applicable):

🧾 Donation Receipt

Yes, I would like a receipt
No receipt needed

✅ Donor Declaration

I voluntarily donate the above-listed equipment to BarnMD for use in its healthcare outreach and development programs. I confirm that I am the legal owner or have authority to donate these items, and that the donation is made without expectation of compensation.

Signature (Typed): Date:

🗂️ For BarnMD Use Only

Received by: Date Received: Location: Condition Verified: Receipt No.: Remarks:

💙 Thank you for your generous support. Together, we’re building healthier communities.

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