Stryker Surgical Application | Our Work

Stryker Kits Application

Requestor Information
Name*
First Last
Email*
Phone*
Organization Name*
Address 1*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Address 2
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How will your organization, work or program use the requested Stryker Kits?*
List proposed country(ies) where Stryker Kits will be used.*
What is your anticipated departure date?
MM slash DD slash YYYY
What Stryker Kit are you requesting (select one)?*
Interested in learning more about or participating in a Clinic Trip
- Yes
How did you hear about Project C.U.R.E.'s Stryker Kit donation program?
Special Instructions*
Terms & Conditions
Do you agree that all of the Stryker supplies will be used outside of the U.S. and will not be sold?*
- Yes
Are you aware of country procedures to clear these products through Customs?*
- Yes
Agree to sign release of liability*
- Yes
Please confirm that you will inform Project C.U.R.E. staff if the Kit is lost or misplaced?*
- Yes
Do you agree to complete Project C.U.R.E.'s Post-Trip Assessment?*
- Yes
- No
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