Order Information Form

This form is a preliminary request in order to help us better understand your need. This is not a binding agreement and your information will not be distributed to third parties.

First Name		Last Name
Organization
Description (please include a brief explanation of your mission, program goals, and target countries)

Contact Information

Address
City	State
Country		Zip Code
Phone Number		Fax Number
Email Address		Website

Which commodity are you interested in? (check all that apply)

	Plumpy’Nut® (for treatment of Severe Acute Malnutrition)
	Plumpy'Sup® (for treatment of Moderate Acute Malnutrition)
	Plumpy’Doz® (for prevention of Acute Malnutrition)
	Nutributter® (for promotion of healthy growth and development)
	Don't know, please send more information

How will you be using the commodity(ies)? (check all that apply)

What is your deadline for the commodity?

Day Month Year

An estimate of the amounts you will need

How did you find out about Edesia?

	School Feeding Program		Children over 3 years
	Disaster Relief		Adolescents
	Community Based Treatment of Malnutrition		Adults w/ HIV/AIDS
	Hospital Stocking		Pregnant Women
	Children from 6 months to 3 years		Other