Request for Cargo Assistance

1 Current: Applicant Information
2 Medical Facility Information
3 Funding
4 Complete

Requestor First Name

Requestor Last Name

Name of Organization

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

Organization/Hospital Website ( i.e. https://projectcure.org )

Address 1

Address 2

City

State

Country

Zip/Postal Code

Phone Country Code

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

Phone

Acknowledgement of Terms

* Please note, under agreements with our donors, Project C.U.R.E. is unable to deliver items within the U.S. and its territories. Project C.U.R.E. does not send individual medical supplies or equipment. All cargo is delivered in 40-foot shipping containers. *

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