Hand-Carry Form

By submitting this application, you agree that it will be reviewed by Medical Bridges. If approved, a standard agreement will be sent to the signatory with specific terms & conditions and an invoice for consideration, signature, and funding.

Name of Organization (if applicable)

Contact First Name

Contact Last Name

Contact Title

Email

Phone Number

Multi-line address

Country/Region

Address

City

Zip / Postal code

Web Address

Is your company a registered U.S. non-profit?

Yes, it is a 501(c)(3)

Yes, but it is not a 501(c)(3)

No

Is your company a faith-based organization?

Yes, it is a church

Yes, but it is not a church

No

Do you have an Employer Identification Number (EIN)?

Yes

No

EIN (if applicable - enter number with no hyphen, please)

Name of Recipient Organization (R.O.)

R.O. Contact First Name

R.O. Contact Last Name

R.O. Contact Title

R.O. Contact Email

R.O. Phone Number

R.O. Website (if applicable)

R.O. Address

Country/Region

Address

City

Zip / Postal code

R.O. Legal Status

Public/Government

Private

Religious

Other

Is your organization a nonprofit registered in the recipient country?

Yes

No

How is the facility funded?

Are the services to the community free of charge?

Yes

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

If 'No', how is cost determined?

Total Population Served

Number of Beds

Number of Patients Served Monthly

Type of Facility

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

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

If your application is approved, when would you need to pick up supplies?

I agree to the terms & conditions