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1119 Commonwealth Ave. Bristol VA. 24201
Toll Free Phone: 800-321-9234 Phone: 276-466-3014


NOTE: We prefer at least 3 weeks notification from receipt of this form in order to ship your product on time.
If you plan to order a large amount (a tractor trailer load) please call Albert Hester, 800-321-9234, ext. 245, to have it approved.

Team Member Ordering First Name: * (Person to contact)
Team Member Ordering Last Name: * (Person to contact)
Team Member Ordering Address: *
Team Member Ordering E-Mail: *
Team Member Ordering City: * Team Member Ordering State: * Team Member Ordering Zip/Postal Code: *
Team Member Ordering Phone: * Team Member Ordering Cell:  

Approved Organization/Ministry Name: *(Please spell out)
Organization/Ministry Address: *
Organization/Ministry City: * Organization/Ministry State: * Organization/Ministry Zip/Postal Code: *
Organization/Ministry E-Mail: *
Organization/Ministry Phone: *  
Kingsway Charities will contact the approved Advising Physician for your Organization/Ministry via email for their approval of your mission trip. Your trip will not be approved until this form is signed by your Physician and emailed back to us.
Name of Advising Physician for Organization/Ministry: *
Address of Advising Physician for Organization/Ministry: *
Advising Physician City: * Advising Physician State: * Advising Physician Zip/Postal Code: *
Email of Advising Physician for Organization/Ministry: *

Please enter dates greater than 3 weeks from today.
Leave a message in the comments box if you need your order sooner.

Leave for Mission: * Return from Mission: * Receive Your Medicines By: *
(Your order will arrive no later than the entered date)
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Number of people going on your Mission Trip: *
Please select third world country you will be traveling to:*
Shipping Address is: *
SHIPPING INSTRUCTIONS:  Please give us the PHYSICAL ADDRESS and PHONE for package delivery
Ship to Name: *
Ship to Physical Shipping Address 1: *
Ship to Physical Shipping Address 2:
Ship to City: * Ship to State: * Ship to Zip/Postal Code: *

(please no abbreviations)
Ship to Phone: * Ship to Cell:
Additional Comments/Information: (Limit 2000 Characters)
Shipping Terms and Conditions:
Shipping as defined by Kingsway Charities includes the actual shipment of the order from our facility to the address you provided. Each customer will be responsible for any additional charges for services requested at time of delivery. These include inside delivery, use of a lift gate or change of address for delivery and re-delivery. These are charges by the freight company, not additional charges from Kingsway.
Please check the information you entered and make sure everything is correct. Click Submit just one time when you are finished and wait for the confirmation screen to load. Thanks.
Any Questions or Issues Contact Us at the Address/Phone Below
Kingsway Charities, Inc
International Medical Missions
1119 Commonwealth Ave.
Bristol, Va 24201
(800)321-9234    (276)466-3014