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Medical Supply Request - Individually Priced Items

This form serves to request medical supplies and equipment priced individually and is designed to meet the needs of local organizations using supplies domestically or groups/individuals hand-carrying medical supplies internationally. If you are interested in shipping a 40-ft container load (bulk pricing) of medical supplies, please return to our website and complete the Medical Supply Request - Container Program form. 

Contact Information

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First Name
Last Name
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If you have not done so already, please email a copy of your State Sales Tax-Exempt certificate to medicalsupplies@partnersforworldhealth.org
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If requesting multiple medical supplies (excluding Durable Medical Equipment), please upload file at next question with specifics of the request.

Spreadsheet preferred; list item descriptions, style/size, quantity, expiration requirements, etc.
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(mm/dd/yyyy)
Required Affirmations

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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Please read the Release of Liability for Durable Medical Equipment, here. Please confirm that you have read the document completely and agree with all of the conditions stated in it. You will be required to sign this form before equipment is released to you.

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