REQUEST

First Name*
Last Name*
Title
Area/Country to be served*
Type of organization*
Organization Name
Project ID (If applicable)
Street Address*
Address (continued)
City*
State*
Zip Code*
Phone Number*
Fax
Website
Email*
Shoe Sizes, Quantities and Gender*
Please fill as follows: Male: X pairs, Sizes: X,X,X Female: X pairs, Sizes: X,X,X
Purpose Statement*
A brief description of how shoes will be distributed to ensure that the recipients are as described in Choose To Care, Inc. Mission Statement. Include name of responsible persons involved in this activity, past history of similar or other distribution activities and what will be achieved as a result of this project.