Hospital Sisters Mission Outreach Order Partner Hand Carry Application

Hand Carry Application for Partners

TIMELINE FOR SUBMISSION OF APPLICATION

Hospital Sisters Mission Outreach requires four weeks’ notice prior to the delivery date in order to process your request.
Once the Application has been approved for processing, Mission Outreach will assign an agency reference number and password for the Applicant or designee to access Mission Outreach’s online inventory. Applicant or designee will begin selection of items for order.
Applicant or designee will notify Mission Outreach when they have completed their order. A list of items that you have selected will then be sent to you for FINAL approval. Also included, will be an estimate for the cost for shipping or mailing, handling, and processing fees.
An invoice will then be generated and sent to the Applicant by the Accounting Department for Hospital Sisters Mission Outreach. This invoice will contain the *FINAL* shipping or mailing cost, handling and processing fees for this order. Upon receipt of invoice, net pay is required within 30 days of receipt of the invoice.

Application Fees

The requesting organization is responsible for the following fees:

Base Fee - A base fee of $30.00 is applied to all orders.
Handling Fee - In addition to the base fee, you will be charged a handling fee of $2.00 per pound.
Shipping/Mailing Costs - When needed, Mission Outreach will attempt to get the best price for shipping/mailing from Springfield to the address designated for delivery by the requesting organization.

Name of country traveling to:
In order to meet your deadline, please provide a delivery date:	Today Please note: Hospital Sisters Mission Outreach requires four weeks notice prior to the delivery date in order to process your request.
Name of partner hospital:
Applicant name:
Applicant title:
Applicant street address:
Applicant city:
Applicant state:
Applicant postal code:
Applicant phone (mobile):	( ) - Second three digits Last four digits
Applicant phone (other):	( ) - Second three digits Last four digits
Applicant email address:
Website:
Recipient information: Name of mission, hospital and/or clinic in country:
How will the community benefit from the medical goods being donated by Hospital Sisters Mission Outreach?:
Has this organization received assistance from Mission Outreach in the past?:	Yes No
How did you hear about Hospital Sisters Mission Outreach?:
List other sources that currently donate (or have donated) medical supplies and equipment to your organization:
Please select one of the following options for pickup or shipping:	Pickup at Hospital Sisters Mission Outreach, 4930 LaVerna Road, Springfield, IL 62707 (If selected, skip the next 7 questions) Ship via UPS
Contact name of the individual that will be receiving items via UPS:
Contact address for UPS:
Contact city for UPS:
Contact state for UPS:
Contact postal code for UPS:
Contact phone (mobile) for UPS:	( ) - Second three digits Last four digits
Contact email address for UPS:
Billing information - Financial responsible party name:
Financial responsible party address:
Financial responsible party city:
Financial responsible party state:
Financial responsible party postal code:
Financial responsible party phone (mobile):	( ) - Second three digits Last four digits
Financial responsible party email address:
Please either accept or decline the terms of authorization written below:	I ACCEPT I DECLINE
Please either accept or decline the terms of recipient agreement written below:	I ACCEPT I DECLINE

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 defined) 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 indemnification 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 officers, 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 benefit 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 profit 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.

Authorization

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 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.

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