Request for Medical Equipment & Supplies

Requestor Information

First Name

Last Name

Requestor Email

Requestor Number

Which of these best describes the requestor?

Organization or Medical Facility Information

Name

Website

Address

Phone number

Additional Information

How did you hear about us?

Number of Recipient Facilities

Recipient Country

Facility #1

Name of Medical Facility

Type of Medical Facility

Number of Beds

Facility #1 Address

Street Address

City

ZIP / Postal Code

Country

Please describe the problems and difficulties that are facing the hospital or clinic?)

Please share any specific known needs for equipment and supplies:

Explain in 300 – 500 words how donated medical supplies and equipment fromour Project. would impact the facility and the surrounding community.

Final Step

There are fees associated with the delivery of a cargo container full of medical supplies which are the responsibility of the client. Are funds currently available to pay the Needs Assessment Deposit and Cargo Container fee in full?

Yes, all funds are currently available. No, all funds are not currently available.

Will your organization be supported with government funding?

Yes, the container will be funded all or in part through the US government, other government, or UN funding. No, government funding not be used to support this container. Unclear. We have not yet determined the source of funding, but it may include US government, other government, or UN funding,

Will you need to fundraise for this project?

How will the funding be secured to cover the associated costs of a C.U.R.E. Cargo container delivery?

Please share a few photos of the hospital/clinic:

Request for Medical Equipment & Supplies

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