Request For Medical Resources

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.

Shipment Sized Desired - Please Check One(Required)

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

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

Requestor's Organization Name (if applicable)

Requestor's First name(Required)

Requestor's Last name(Required)

Position within Organization

Email (Required)

Primary Phone Number(Required)

WhatsApp Phone Number

Multi-line address

Country/Region

Address

City

Zip / Postal code

Is your company a faith-based organization? (Required)

Yes

No

Website

Is your company a registered U.S. nonprofit? (Required)

Yes

No

Do you have a Employer Identification Number (EIN) or VAT ID?

Yes

No

If yes, please enter your EIN or VAT below.

Overseas Beneficiary Medical Facility Name(s) (Required)

Overseas Contact Person's First Name (Required)

Overseas Contact Person's Last Name (Required)

Overseas Contact Person's Position Within Organization

Overseas Contact Person's Email (Required)

Overseas Contact Person's Phone/WhatsApp(Required)

Overseas Requesting Beneficiary Organization/Facility Address

Country/Region

Address

City

Zip / Postal code

Overseas Organization/Facility Owned/Operated By (Required)

Is your organization a nonprofit registered in the recipient country? (Required)

Yes

No

How is your facility funded? (Required)

Are the services to the community free of charge?(Required)

Yes

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

How is the cost to the community determined? (Required)

Number of Patients Served Monthly (Required)

Total Population Served (Required)

Number of Beds

Type of services offered at your facility? (Required)

How would your organization use this donation? Who would benefit? (Required)

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

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?

Yes

No

By submitting this application, you acknowledge that it will be reviewed by Medical Bridges. If approved, a standard agreement outlining specific terms and conditions will be sent to the signatory for consideration and signature. An invoice, excluding shipping costs, will also be provided for your review and funding.

I agree to the terms & conditions, I understand that the processing fee doe not include the cost of shipping.