Form B2: Donor Intent Form (Organization)
Please complete this form if your organization interested in becoming a donor for COVID-19 response. Personal information submitted will be used only for communication and monitoring purposes. Rest assured that it will be treated with utmost confidentiality.
In compliance with Administrative Order No. 27, s. 2020, we strongly encourage donors of medicines, medical equipment and supplies, and other health products to address COVID-19, whether given to the National Government as a whole or to the Department of Health (DOH) to inform the Office of Civil Defense (OCD) directly for inventory purposes and to help the Government ensure equitable allocation and distribution of assistance.
(Maaaring sagutan ang form na ito kung ang inyong organisasyon ay interesadong maging donor para sa COVID-19 response. Makakasiguro ka na iingatan at gagamitin lamang namin ang iyong personal na impormasyon para sa pakikipag-ugnayan at monitoring.
Bilang pagsunod sa Administrative Order No. 27, s. 2020, hinihikayat namin ang mga nagbigay ng donasyong gamot, kagamitang medikal, at iba pang produktong pangkalusugan para sa pagtugon sa COVID-19 sa national government o Department of Health na ipagbigay alam sa Office of Civil Defense (OCD) para maitala at masiguro ang tamang alokasyon at distribusyon.)
* Required
GENERAL INSTRUCTIONS
Please answer N/A if the question is not applicable. If you would like to provide additional information which cannot be captured by the questions, please include these under the " Additional Information" which can be found near the end of this form.
(Maaaring sumagot ng "N/A" kung hindi naaangkop ang tanong. Kung nais mong magbigay ng karagdagang impormasyon na hindi saklaw ng tanong sa bahaging ito, maari mong ilagay ang mga ito sa " Karagdagang Impormasyon" na matatagpuan malapit sa dulo ng form na ito.)
Profile of the Organization
Name of Organization
*
Your answer
Complete Address (House No., Street, Subdivision, Barangay, City/Municipality, Province)
Block and Lot No./ Floor and Building No.
*
Your answer
Street/Subdivision
*
Your answer
Barangay
*
Your answer
City/Municipality
*
Your answer
Province (If the organization is based in NCR, please answer N/A)
Your answer
Region
*
Choose
National Capital Region (NCR)
Cordillera Administrative Region (CAR)
Region I
Region II
Region III
Region IV-A (CALABARZON)
MIMAROPA
Region V
Region VI
Region VII
Region VIII
Region IX
Region X
Region XI
Region XII
Region XIII (Caraga)
Bangsamoro Autonomous Region in Muslim Mindanao (BARMM)
Classification (Klase ng Organisasyon)
*
Non-Government Organization
Professional Association (Samahan ng mga Propesyonal)
Academe-based/Alumni Association (Samahan sa loob ng Paaralan/Samahan ng mga Nagsipagtapos)
Church-based/Religious (Samahan ng Kaakibat ng Relihiyon)
Employees’ Association/Labor Union (Samahan ng mga empleyado/Unyon ng Manggagawa)
Private Company/Corporation (Pribadong Kompanya/Korporasyon)
Others (Iba pa)
If others, please specify...
Your answer
Government Agency where your organization is registered/accredited (Ahensya ng pamahalaan kung saan rehistrado ang inyong organisasyon)
Securities and Exchange Commission (SEC)
Department of Labor and Employment-Bureau of Rural Workers (DOLE-BRW)
Cooperative Development Authority (CDA)
Department of Trade and Industry (DTI)
Department of Social Welfare and Development (DSWD)
National Youth Commission (NYC)
Local Government Unit (Lokal na Pamahalaan)
Others (Iba pa)
Not yet registered (Hindi pa rehistrado)
If others, please specify... (Kung iba pa, tukuyin)
Your answer
Year Established
*
Your answer
Head of Organization
*
Your answer
Focal Person/Coordinator
*
Your answer
E-mail address
*
Your answer
Mobile/Telephone No.
*
Your answer
Website
Your answer
Facebook page URL , if any
Your answer
Other social media accounts, please provide organization’s username
Your answer
Type of Donation
I want to donate
*
Goods (Gamit)
Money (pera)
Required
If goods, please specify...
Your answer
If money, please specify how much...
Your answer
Source/s of Funds for the Donation
Own money (Sariling pera)
Contribution of friends or members of an organization (Kontribusyon/ambagan mula sa magkakaibigan o mga miyembro/kasapi ng organisasyon)
Public Donation Drive (Pampublikong paglikom ng donasyon)
Others (Iba pa)
If others, please specify...(Kung iba pa, tukuyin...)
Your answer
Direct Recipient of Donation (Organisayon/Grupo kung saan nagbigay ng donasyon o serbisyo)
*
Department of Health ( Kagawaran ng Kalusugan)
Government Hospital ( Pampublikong Ospital/Pagamutan)
Private Hospital (Pribadong Ospital/Pagamutan)
Non-Government Organization
Company/Corporation (Pribadong organisasyon)
Local Government Unit (Lokal na Pamahalaan)
Individual (Indibidwal)
Others (Iba pa)
Required
Please specify the name of the individual/organization which is chosen as direct recipient. (Tukuyin ang pangalan ng indibidwal o organisasyon na piniling pagbigyan ng donasyon)
*
Your answer
In case your target recipient institution does not like to accept donations, is your organization willing to be referred to other institutions? (Kung ang institusyon na gustong pagbigyan ay hindi nais tumanggap ng donasyon, ang iyo bang organisasyon ay bukas na magbigay sa ibang imumungkahi na institusyon?)
*
Yes (Oo)
No (Hindi)
Additional Information regarding your donation (Karagdagang impormasyon tungkol sa donasyon)
Your answer
Thank you for answering this form.
Later on, we will ask you to accomplish a report form where you can provide information on the donation you have given.
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