Health Volunteers Overseas

HVO is a network of health care professionals, organizations, corporations and donors united in a common commitment to improving global health through education.

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Financial Contribution Form

This is HVO's on-line financial contribution form. Please complete this form and submit on-line upon returning from your volunteer assignment.

Bold fields are required.

Personal Information

Please enter your name, degrees and specialities.

Title

First Name:

Middle Name

Last Name:

Suffix

Contact Information

Mailing Address

Street Address

Address line 2

City

State/Province

Postal / Zip Code

Country

Service Information

Country of Service

Date of Departure to Site mm/dd/yyyy

Date of Arrival Home mm/dd/yyyy

Part I - Expanses

Note:

All expenses incurred directly by you should be listed below. If you took any equipment, supplies or other items donated by companies or individuals, please complete Part II. This form will not accept commas in the expense fields. Please use only numbers and decimal points

Travel & Living Expenses

Air Fare $ Dollars

In-Country Travel $ e.g. rail, auto, bus; Dollars

Food & Lodging $ Dollars

Incidentals $ Passport/Visa, Entry/Exit Tax, Vaccinations etc; Dollars

Communications $ Telephone Calls/Faxes etc.; Dollars

Subtotal $ Dollars

Other Items:

Item#1 $ Dollars

Item#2 $ Dollars

Subtotal $ Dollars

Supplied/Equipment:

Item#1 $ Dollars

Item#2 $ Dollars

Item#3 $ Dollars

Item#4 $ Dollars

Item#5 $ Dollars

Item#6 $ Dollars

Item#7 $ Dollars

Item#8 $ Dollars

Item#9 $ Dollars

Subtotal $ Dollars

Part 2 - Received Items/Donations

Note:

Please list all donations of supplies, equipment, and other materials that you received on behalf of HVO for use overseas. In order to comply with IRS and auditing requirements, we ask that you attach an itemized list (a packing list or invoice will suffice) or fill out the section below for all such donations. All donations over $250 will be acknowledged by a letter from HVO, if the appropriate information is provided.This form will not accept commas in the expense fields. Please use only numbers and decimal points

Donor's Name & Address Items Value