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In-Kind Contribution Form
Please submit a separate form for each implementing agency

1. Name of  Donor:*                   

2. Implementing  Partner:*  


Please indicate:
Contribution against 2005 Appeal              Contribution for general emergency activities

3. Sector :
Please tick  applicable sector(s) and, if available, provide allocated item and quantity in the first box (Item and Quantity) and indicate relevant regions in the second box (Code) by using the equivalent regional codes stated here below.

Regional Codes:
Afar=1             Amhara=2       Beneshangul  Gumuz=3      Dire Dawa=4        Gambella=5      Harari=6   Oromiya=7     SNNPR=8         Somali=9                             Federal/Country Wide=10

                          Item  and Quantity                       Code (1, 2, 3, ...)
Health and Nutrition                                                        
Water and Sanitation                                              
Shelter and Household Items                                 
Disaster Management and                           
     Capacity Building
Post Emergency Recovery                           
     and Rehabilitation  
Logistics and Operational Support                      
Other relief sector                                      

4.  Status of Contribution:
Please indicate status of contribution
 Pledged        Confirmed    

Contact Person

Please indicate name, phone number and email of the person in your organization whom we can contact for contribution information

Phone Number:

*  Required Information

To ensure accurate and timely reporting on humanitarian contributions, we will be contacting you for contribution updates on a quarterly basis.