MedicIndia has established wide connections with various organizations throughout India.  With your help, MedicIndia is looking to support these organizations through medical donation.  Please complete the below form and describe the state of the product to be donated.  MedicIndia will facilitate transportation of the product overseas.  Currently, MedicIndia will not be posting NGO or organization needs.  If your organization is looking for medical donations, please contact us via email.

Please provide the following contact information:

Name:  

Title:  

Organization:  

URL:  

Street Address:  

Address:  

City:  

State/Province:  

Zip Code:  

Country:  

Work Phone #:  

Fax #:  

E-mail:

Best reached by: 

Please provide the following product information:

Product Name:  

Model:  

Version Number:  

Operating System:  

Product Code:  

Serial Number:  

Quantity:  

Please describe the product(s):

Enter the date of the product was purchased.

-- mm/dd/yy

Please describe the state of the product. Note any scratches, dents, malfunctions, etc.

State to be donated to:

Please describe other preferences, if any: