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1-914-920-5081 info@afyafoundation.org

APPLICATION TO REQUEST MEDICAL SUPPLIES

Please do not leave any lines blank. If something does not apply, please fill in "n/a" for that specific question. If you do not know and answer to a question, indicate where you may need guidance or more information.

1. Today's Date:

2. Name and Contact Information (MD, DNP, RN, PA, CNM, ect.):

3. Email Address:

4. Organization you are representing:

5. Website:

6. Social Media Handles?

RECIPIENT ORGANIZATION/HOSPITAL/INSTITUTION/HEALTHCARE FACILITY

Name of Facility:

Facility Address:

Facility City:

Facility Country:

Name of Person we should Contact at Facility:

Title of Contact & Credentials:

Year the Facility Opened:

Annual Budge of Institution ($USD):

Total Number of Patients Served Per Year:

Top 5 Treatments or Services (E.g.: HIV Testing, Family Health, Dental, Etc.)

Total Staff at Facility:

7. Do you have a Biomedical Engineer or Clinical Engineer on Staff? If YES, please provide contact information. If NO, how is biomedical equipment and instrumentation evaluated and fixed?

Staff Name (with certifications):

Staff Title:

Staff Email Address:

Staff Phone 1:

Staff Phone 2:

8. What is the environment like where the equipment is stored? (E.g.: damp, hot, dusty, etc.)

9. Describe where the supplies will be stored once delivered or picked up:

TRANSPORTATION

10. If you require AFYA to deliver supplies directly to the recipient country, please complete the following:

Does in-country recipient organization have written approval for importation duties and customs fees waived? If yes, please attach documents.

YesNo

What is the requested destination ocean port?

Consignee/Recipient Information:

This is the entity that is the official recipient of the donated medical supplies. The consignee may be the institution utilizing the materials OR may be a charitable organization receiving the donation for onward delivery to the entity who will use and/or distribute the donated materials.

You must provide a physical address. We cannot deliver medical supplies to a P.O. Box.

Organization Name:

Contact Name:

Address:

City:

Country:

Email Address:

Phone 1:

Phone 2:

11a. Is this organization a registered charity

YesNo

11b. If yes, what country?

11c. Attach any registration and determination info

12. Does this organization have duty-free exempt status for importation?

YesNo

14. Notify Party/Clearing Agent Information

We will send all official shipping documents by courier to this individual at the address provided. The individual will utilize the documents to clear customs and remove the container from port.

Name:

Email:

Phone 1:

Phone 2:

Fax:

Address:

City:

Country:

Upon completion of this document, please be sure you attach a list of requested materials including consumable/disposable supplies, single use items, durable medical goods, electrical biomedical equipment, and surgical tools.


I understand that submitting this application does not guarantee The AFYA Foundation will fulfill this request. AFYA relies on medical supplies donations from parter organizations. We will strive to include the majority of your requested items in your shipment. AFYA will not ship any pharmaceutical medications, please remove these from your wishlist before submitting.

Please attach your list:

Your Name as Your Digital Signature:

Date of Digital Signature:

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