Request for Cargo Assistance

1 Current: Applicant Information
2 Medical Facility Information
3 Complete

Requestor First Name

Requestor Last Name

Name of Organization

If not affiliated with an organization please type "Self".

Organization/Hospital Website

Address 1

Address 2

City

State

Country

Zip/Postal Code

Phone Country Code

If located in the United States, this would be 1.

Phone

Email

Which category best describes the Requestor?

Representative of Medical Facility Recipient

Representative of Partner Organization

Other

Check all that apply.

How did you hear about us?

Who have you been working with at Project C.U.R.E.? Please select

I have verified that the information on the page is correct

Facility 1

Name of Medical Facility to Receive Assistance

Type of Medical Facility

City Where Medical Facility is Located

Country Where Medical Facility is Located

Specific Known Needs

Facility 2

Name of Medical Facility to Receive Assistance

Type of Medical Facility

City Where Medical Facility is Located

Country Where Medical Facility is Located

Specific Known Needs

Facility 3

Name of Medical Facility to Receive Assistance

Type of Medical Facility

City Where Medical Facility is Located

Country Where Medical Facility is Located

Specific Known Needs

I have verified that the information on the page is correct

Are Funds Currently Available to Pay for the Cargo Container Project Fee in full?

Yes, all funds are currently available.

No, no funds are currently available.

Are Funds Currently Available to Pay the Needs Assessment Deposit Fee in Full?

Yes, all funds are currently available.

No, no funds are currently available.

Will your organization be supporting through government funding?

Yes, the container will be fully funded all or in part through U.S., other government or UN funding.

Unclear, we have not yet determined the source of funding, but it may include U.S., other government, or UN funding

No government funding will be used to support this container

I have verified that the information on the page is correct