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.*