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Container Application

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

Mission Outreach team stands next to imaging equipment in their warehouse Mission Outreach team stands next to imaging equipment in their warehouse
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.
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.
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.
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.
Please describe the hospital(s)/clinics(s) which will use the donated medical supplies and equipment.
Example: Facility A (3 beds), Facility B (4 beds), Facility C (8 beds)
Mark only one
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.
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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 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 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.




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.