Partners for World Health · Medical Supply Request

Thank you for contacting Partners for World Health (PWH) to fulfill your request for medical supplies and equipment on a 40-ft container shipment. The PWH Container Program provides a wide range of medical supplies, machines and equipment to an individual or organizations in need. Fees associated with the container of supplies offset the expenses associated with collecting, sorting and storing the supplies. Shipping costs are passed directly to the customer. Please take a few moments to carefully complete this form. This will help us serve you more effectively and efficiently! Someone will contact you regarding your request within 3-5 business days.

Basic Information

Your Name

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Prefix

First Name

Last Name

Suffix

Your Email

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Verify Email

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Your Phone Number

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Name of the Medical Facility/Organization you represent (can be multiple)

*

Consignee & Notify Party Information

Complete this section carefully. The details will be used to arrange shipment and estimate costs from our headquarters in Portland, Maine, USA to the final destination.

Official Name of the Consignee

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This is the name of the BUSINESS ENTITY that will appear on the official shipping documents and who will be financially responsible for the receipt of the shipment.

Tax ID Number of the Consignee

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Consignee must be a business entity with Tax ID Number

Email Address of the Consignee

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Consignee must be a business entity with Tax ID Number

Name of the Notify Party/Primary Contact

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This is the name of the INDIVIDUAL that will appear on the official shipping documents and who will be the primary contact for receipt of the shipment.

Email Address of the Notify Party/Primary Contact

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This is the email address of the INDIVIDUAL listed as the Notify Party/Primary Contact listed above

Official Name of the Recipient Organization or Facility where goods will be shipped

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Note this MAY be the same as the Official Name of the Consignee, above. This is the name that will appear on the official shipping documents and who will be financially responsible for the receipt of the shipment.

Address of the Organization or Facility (this is the final destination of the container shipment)

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

City, Country of the sea port which will receive the container

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This may not be the final destination of the container, but the port of entry to land.

Legal Status of the Recipient Organization/Facility

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Does this shipment require a Clearing Agent at the port of entry?

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Yes - please assign one

No - we have our own

How is the Medical Facility/Organization funded?

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Fee for Service

Government

Charitable Funds

Other

Will the goods be distributed beyond the Consignee Organization or Facility?

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If your Organization/Facility will collect the goods and distribute them among a network or multiple collaborating organizations, select Yes. If your organization will be the sole recipient of the goods, select No.

Yes

No

Import Information

Complete this section carefully; it will determine how the container contents are prepared and may result in additional time needed for shipment if responses are updated later in the process.

Does the destination country allow import of expired medical supplies and equipment?

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Yes

No, supplies must expire within __ months of arrival

If you answered No to the question above, specify how many months

i.e. if the medical supplies/equipment must expire no sooner than 6 months AFTER ARRIVAL to the port of entry, write "6 months".

Does the destination country require pre-inspection of medical supplies and equipment to be imported?

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Yes, the process is as follows:

No

If you answered Yes to the question above, describe the process for pre-inspection:

Does the destination country restrict the importation of "refurbished" or "used" goods?

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Yes, the restrictions are:

No

If you answered Yes to the question above, describe the restrictions:

What paperwork does the destination country need in order to approve the shipment PRIOR to loading?

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Is there anything else PWH needs to know regarding the destination country's import regulations?

*

Additional Questions

Desired Date of Shipment

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(mm/dd/yyyy)

Who will fill out the required, subsequent Healthcare Facility Assessment Form and Inventory Request list? (These forms will be sent to you upon submission and acknowledgement of this form.)

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Person's name and qualifications

Required Affirmation:

The individual completing this form guarentees that the supplies I receive from Partners for World Health, will be administered by the medical professional listed above or by others under his direction for the benefit of those served by the institution above. I understand that these supplies are donated and as such have no commercial value and that the items are not to be sold, resold, or exchanged for profit or gain. I further attest that I have read and agree to receive donated items from Partners for World Health according to the pre-disclosed stipulations.*

I understand and agree to the above statement:

*