Hospital Sisters Mission Outreach Order Container Application

Container Application

Please complete this form to request one of Hospital Sisters Mission Outreach containers of medical supplies and equipment.

Your Name:
What organization do you represent?:
Name of the organization serving as consignee:	Shipping the container: Consignee - This is the organization which appears on official shipping documents as the recipient of the container. In some cases the Consignee is the healthcare institution which will utilize the donated medical supplies. In other cases it is a charitable organization which will receive the container and give the donated medical supplies to a local healthcare institution. The Consignee must demonstrate tax-exempt status and import licensure as required by recipient country.
Contact name for the organization:
Ship to address:	Please label exactly as it should appear on official shipping documents (Street, City, State/Province, Postal Code, etc.). DO NOT PROVIDE A P.O. BOX.
Ship to city:
Ship to country:
What is the legal status of this organization?:
Will a healthcare institution being using the donated supplies?:	Yes No
Individual or organization serving as notify party:	This is the person to whom official shipping documents will be mailed via ground courier. This person will use the shipping documents to remove the container from the port.
Contact name:
Contact email:
Contact work phone:
Contact mobile phone:
Contact fax:
Contact address:
Contact city:
Contact country:
What is the ocean port where you wish the container to be sent?:	Hospital Sisters Mission Outreach ships the container to the ocean port nearest to the consignee. The consignee is responsible for transporting the container from the port to the hospital(s) where the medical supplies will be used.
Do you currently have permission for duty-free import?:	Yes. I will e-mail or fax a copy of the approval letter to Hospital Sisters Mission Outreach at ratish.kumar@mission-outreach.org. No, not yet, but I am working on it. I will send a copy to Hospital Sisters Mission Outreach when I receive it.
What laws does your country have regarding importation of donated medical supplies and equipment? Check all that apply:	"Invasive" items that enter the body may not be imported Refurbished equipment may not be imported Equipment must include manuals All items must be inspected prior to shipping Consignee must obtain pre-approval of duty-free import prior to unloading Other
If other, please explain:
Items that expire within "X" months may not be imported:
Name of the healthcare facility:	Please describe the hospital(s)/clinics(s) which will use the donated medical supplies and equipment.
Address:
City:
Country:
Phone:
Fax:
Website:
Contact person at healthcare facility:
Title:	Title of the contact person at the healthcare facility
Email:
Work phone:
Mobile phone:
What is the legal status of the healthcare facility? Check all that apply:	Private - for profit Public/governement Private - not for profit Other
If other, please explain:
How many facilities will utilize the items sent in this shipment?:
Name the facilities and the number of beds in each facility:	Example: Facility A (3 beds), Facility B (4 beds), Facility C (8 beds)
What type of area are these healthcare facilities located in?:	Urban Rural Other
If other, please explain:
How are these facilities funded?:	Fee for service Other
If other, please explain:
What is the approximate annual budget?:
Total number of adult patients treated per month:
Total number of pediatric patients treated per month:
What are the major health problems in this area? Check all that apply:	Malaria HIV/Aids Cholera Hepatitis A & B Dengue Fever Typhoid Fever Yellow Fever Parasites Ebola Other
If other, please explain:
What are the biggest problems this healthcare facility is facing? Check all that apply:	Funding Bio-tech support Supplies Access to facility Staffing Infrastructure Training/education Referral for tertiary care Other
If other, please explain:
What medical services are provided at this healthcare institution? Check all that apply:	Primary care General medicine Pediatrics X-ray/imaging services Dental Mental health Family planning Emergency care Intensive care Laboratory Nutritional Surgery Obstetrics/Gynecology Orthopedics Endoscopy Eye care Other
If other, please explain:
Please indicate the number of physicians at this healthcare institution:	Less than 5 5-10 10-15 Greater than 15
Please indicate the number of midwives at this healthcare institution:	Less than 5 5-10 10-15 Greater than 15
Please indicate the number of biomedical technicians at this healthcare institution:	Less than 5 5-10 10-15 Greater than 15
Please indicate the number of laboratory technicians at this healthcare institution:	Less than 5 5-10 10-15 Greater than 15
Please indicate the number of surgeons at this healthcare institution:	Less than 5 5-10 10-15 Greater than 15
Please indicate the number of nurses at this healthcare institution:	Less than 5 5-10 10-15 Greater than 15
Please indicate the number of dentists at this healthcare institution:	Less than 5 5-10 10-15 Greater than 15
Please indicate the number of community health workers at this healthcare institution:	Less than 5 5-10 10-15 Greater than 15
Please indicate the number of nutritionists at this healthcare institution:	Less than 5 5-10 10-15 Greater than 15
Please indicate the number of anesthesiologists at this healthcare institution:	Less than 5 5-10 10-15 Greater than 15
Other comments about this institution:
What electrical voltage is used?:	110 volts, 50 Hz 110 volts, 60 Hz 220 volts, 50 Hz 220 volts, 60 Hz
How is oxygen delivered? Mark only one:	Central oxygen Bottled oxygen No oxygen available
How are items sterilized?:	Central oxygen Bottled oxygen No oxygen available
If your supply voltage is not 110 V/60 Hz, you may need additional transformers to properly operate the equipment you receive. At your request, Hospital Sisters Mission Outreach can purchase transformers for you for an additional cost.:	I would like to discuss with Mission Outreach the option to purchase transformers at an additional cost. The receiving organization has the ability to convert upon arrival.
Is there a stable electrical current?:	Yes No
Is there a generator on the premises?:	Yes No
Is there running water?:	Yes No
Is there internet access?:	Yes - dial up internet Yes - DSL/cable internet No A username and password will be sent to the applicant. This will provide the healthcare institute access to review items and select products from our online inventory list.
What equipment do you wish to receive for this healthcare institution?:	Anesthesia machine Cast saw Centrifuge Colposcope Defibrillator/monitors Dermatome Diagnostics ultrasound with probe EKG recorder (dual) Electrosurgical unit Endoscopies equipment Fetal doppler Fetal monitor Humidifier Hyfrecator Infant incubator Infant warmers Suction pumps Surgical head light Vaporizers Ventilator Lab dryers Lab incubators Microscope - surgical and lab Microscope - binoculars Monitor - Cardiac and NIBP Nerve stimulator Ophthalmic equipment (slit lamps, etc.) Ophthalmoscope Otoscopes Oxygen concentrator Patient warmers Pulse oximeter Shakers Spectrophotometer (Note: All equipment Hospital Sisters Mission Outreach receives is donated. Although we make every effort to send you what you ask for, we may not have all the items in stock).
Other equipment requests - Type in the name of the piece(s) you would like to request. Please separate each request with a comma.:
Equipment comments:
Name of sponsoring organization:	The sponsoring organization may be the recipient organization, another organization or individual responsible for payment. See below the form for funding information.
Name of contact:
Sponsoring organization address:
Sponsoring organization city:
Sponsoring organization country:
Sponsoring organization phone:
Sponsoring organization fax:
Sponsoring organization website:
Are funds currently available to cover shipping and handling fees?:	Yes No
If funds are not available, when is funding expected?:	Today
Contact person's name (individual responsible for the shipping and handling fees):
Contact person's title:
Contact person's email:
Contact person's work number:
Contact person's mobile number:
Sponsoring organization comments:
If you have communicated with a particular member of the Hospital Sisters Mission Outreach staff prior to this application, please list their name:
Please list two names and their email addresses of persons willing to serve as references for your organization:
By clicking the button you accept the terms written in the recipient agreement below:	I ACCEPT

Recipient Agreement

The Applicant understands that the medical supplies, equipment, and other items (“Donated Goods”) available from the Hospital Sisters Mission Outreach Corporation (“Mission Outreach”) are being made available strictly on an “as-is, where-is” basis. The Applicant accepts the Donated Goods “as is, where is” with all faults, and acknowledges that the inspection for any defects and the safe operation of the Donated Goods is solely the responsibility of the Applicant. MISSION OUTREACH MAKES NO WARRANTIES OF ANY KIND, INCLUDING WITHOUT LIMITATION, ANY IMPLIED WARRANTY OF MERCHANTABILITY OR FITNESS FOR ANY PARTICULAR PURPOSE. TO THE MAXIMUM EXTENT PERMITTED BY LAW, MISSION OUTREACH SHALL NOT BE LIABLE AND HEREBY DISCLAIMS LIABILITY IN CONNECTION WITH THE DONATED GOODS, INCLUDING WITHOUT LIMITATION, LIABILITY FOR ANY COMPENSATORY, PUNITIVE, INCIDENTAL, EXEMPLARY, CONSEQUENTIAL OR SPECIAL DAMAGES OF ANY KIND OR NATURE WHATSOEVER.

Each Applicant and any responsible manager of any such Applicant assumes full responsibility for making an independent determination of the appropriateness of the Donated Goods (or any part thereof) before using them and for the transportation and use of the Donated Goods in accordance with applicable law. To the maximum extent permitted by law, the Applicant fully accepts and assumes all risks and all responsibility for losses, costs, and damages that the Applicant, its agents, representatives, members, directors, officers, employees, agents, contractors, patients, and transferees (“Users”) may incur as a result of the Donated Goods or their use or transportation, including without limitation personal injuries, illness, damage or loss to property, and death.

Mission Outreach and the Applicant recognize that this agreement shall release the Indemnities (as hereinafter defi ned) from any and all liability for personal injury and any other type of injury, loss, cost, or expense arising from the use or transportation of the Donated Goods. The Applicant acknowledges that the consideration for this release and indemnifi cation is the donation of the Donated Goods themselves or of the use thereof.

By making an application for the receipt of such Donated Goods and by accepting such Donated Goods, the Applicant agrees to waive and relinquish all claims against Mission Outreach and its donor facilities, and their respective offi cers, agents, directors, employees, and volunteers (the Indemnities”), and further agrees to indemnify, hold harmless, and defend the Indemnities from and against any and all liability, loss, damage, cost or expense (whether to person or property), including without limitation the reasonable fees of attorneys and paralegals, due to, or arising or alleged to have arisen out of the use, receipt, acceptance or transfer of the Donated Goods.

The Applicant guarantees that the Donated Goods received as donations from Mission Outreach will be administered by the Applicant or by others under the direction of the Applicant for the benefi t of those served by the Applicant. The undersigned understands that these Donated Goods have no commercial value and that the Donated Goods are not to be sold, resold or exchanged for profi t or gain. The undersigned further attests that the undersigned has read and agrees to receive the Donated Goods from the Mission Outreach Program according to the stipulations above.

If the undersigned is an entity, the undersigned represents and warrants that the undersigned has the authority to commit the entity on whose behalf the undersigned is signing this document.

BY SUBMITTING THIS FORM:

The applicant authorizes Hospital Sisters Mission Outreach to (1) investigate all statements contained in this application; (2) contact references or any other persons who can provide information relative to consideration of this application; (3) and make any other inquiries relevant in arriving at a decision regarding application for donation. I consent to any contacted person to provide information and I covenant not to sue any such person for information provided.

If the undersigned is representing an entity, the undersigned represents and warrants that the undersigned has the authority to commit the entity on whose behalf the undersigned is signing this document.

Review the funding guide by clicking here.

Please note: The estimated costs provided in the grid within the above document cover door to port expenses. Recipients should familiarize themselves with in-country costs prior to shipment.

Attention: Payment for shipping and handling charges must be received prior to booking shipments. Shipments should be booked within three months of completion of the online ordering process. Supplies and equipment on completed orders, not sent within three months, will be returned to inventory and made available to other recipients.

In order to help define the terms in our applications, click here.

For frequently asked questions, click here.