Request for Medical Purchasing Service

Information About You

Your name:

Your email address:

Your postal address (no apostrophes please):

Name of your mission agency (alphabetic characters only, please):

Email address of your mission:

Postal address of your mission (no apostrophes please):

Information about what you need

Please provide a list of medicines and quantities required, using only alphabetic characters and numbers:

Maximum price to pay (in pounds sterling): £

(Please enter numbers only or zero to indicate that you have no limit in view.)

How would you like the item sent to you?

Destination country:

(This is only required if medicines are to be delivered to an address in the UK.)

Please provide an address for UK delivery:

(If you wish to have everything sent directly abroad, please leave this blank.

What arrangements will you make for payment?

(Please provide an account number for your organisation or detail alternative options.)

Please type the characters displayed on the left into the box on the right. All alphabetical characters are shown in uppercase but you may type them as lowercase. The number zero is indicated with a diagonal line whilst the letter O is clear inside.

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