Request for Medical Resources-Medical Bridges

Shipment Size Desired - Please Check One

40" x 48" Pallet ($1,000 processing fee excluding shipping)

20-Foot Shipping Container ($10,000 processing fee excluding shipping)

40-Foot Shipping Container ($19,000 processing fee excluding shipping)

Organization Name (if applicable)

First Name

Last Name

Position Within Organization

Email

Primary Phone Number

Type of Phone

Home

Office

Cell

WhatsApp Phone Number

Address 1

Address 2

City

State

Zip

Country

Is your company a faith-based organization?

Website

Is your company a registered U.S. nonprofit?

Do you have an Employer Identification Number (EIN)?

If yes, please enter your EIN below

Overseas Requesting Beneficiary Name

Contact First Name

Contact Last Name

Position Within Organization

Contact Email

Contact Phone

Contact Address

Contact Country

Contact Website

Facility Owned/Operated By:

Legal Status

Legal Status 'Other' Explanation

Is your organization a nonprofit registered in the recipient country?

Yes

No

How is your facility funded?

1000

Are the services to the community free of charge?

Yes

No (If no, please explain below what is paid and how the cost is determined.)

How is the cost to the community determined?

Number of Patients Served Monthly

Total Population Served

Number of Beds

Type of services offered at your facility?

Type of Services if 'Other'

How would your organization use this donation? Who would benefit?

1000

List items that should not be sent due to customs embargo or restrictions, cultural sensitivity, or environmental conditions:

Desired port of entry

If approved, what is your timeframe for shipping?

Would you like Medical Bridges to provide you with a list of freight forwarders to obtain quotes for shipping costs?

Terms & Conditions

By submitting this application, you agree that it will be reviewed by Medical Bridges. If approved, a standard agreement with specific terms & conditions will be sent to the signatory for consideration and signature. An invoice (excluding shipping cost) will also be sent for your review and funding.

I agree to the terms & conditions