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Medical Supply Request - Container Shipment
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
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Prefix
First Name
Last Name
Suffix
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Consignee 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.
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This is the name that will appear on the official shipping documents and who will be financially responsible for the receipt of the shipment.
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This is the name that will appear on the official shipping documents and who will be financially responsible for the receipt of the shipment.
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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This may not be the final destination of the container, but the port of entry to land.
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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.
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.
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i.e. if the medical supplies/equipment must expire no sooner than 6 months AFTER ARRIVAL to the port of entry, write "6 months".
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Additional Questions
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(mm/dd/yyyy)
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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.*

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