Request Medical Equipment & Supplies

1Applicant Information

2Recipient Medical Facility Information

3Funding

Requestor Information
Requestor Name*
First Last
Requestor Email*
Requestor Phone Number*
Include the country code. For example, the US country code is 1.
Which of these best describes the requestor?*
- Representative of sponsor organization
- Representative of medical facility recipient
- Representative of partner organization
- Individual not affiliated with an organization or medical facility
Requestor Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Organization or Medical Facility Information
Name of Organization or Medical Facility*
Website
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone for Organization or Medical Facility
Include the country code. For example, US country code is 1.
Email Address for Organization or Medical Facility
If different from requestor email.
Additional Information
How did you hear about us?*
Who have you been working with at Project C.U.R.E.?*

Number of Recipient Facilities*
Facility #1
Name of Medical Facility to receive assistance*
Type of Medical Facility*
Address*
City State / Province / Region Country
What is the current condition of the hospital/clinic, and what are primary challenges at the hospital/clinic that you are seeking to overcome?*
Please share any specific known needs for equipment and supplies:*
Facility #2
Name of Medical Facility to receive assistance*
Type of Medical Facility*
Address*
City State / Province / Region Country
What is the current condition of the hospital/clinic, and what are primary challenges at the hospital/clinic that you are seeking to overcome?*
Please share any specific known needs for equipment and supplies:*
Facility #3
Name of Medical Facility to receive assistance*
Type of Medical Facility*
Address*
City State / Province / Region Country
What is the current condition of the hospital/clinic, and what are primary challenges at the hospital/clinic that you are seeking to overcome?*
Please share any specific known needs for equipment and supplies:*

There are fees associated with the delivery of a C.U.R.E. Cargo container, which are the responsibility of the client. Are funds currently available to pay the Needs Assessment deposit and C.U.R.E. Cargo container fee in full?*
- Yes, all funds are currently available.
- No, all funds are not currently available.
Will you need to fundraise for this project?
- Yes
- No
If fundraising, how long do you anticipate it will take to raise the required funds?
- 0 to 3 Months
- 3 to 6 Months
- 6 to 9 Months
- 9 Months or Longer
How will the funding be secured to cover the associated costs of a C.U.R.E. Cargo container delivery?*
Please share any information and stories that you feel would be helpful in considering this Request for Assistance:
Please share a few photos of the hospital/clinic:
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 15 MB, Max. files: 5.
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Requestor Information