Request for Medical Equipment & Supplies

Requestor Information

Requestor Name(Required)

First Last

Requestor Email(Required)

Requestor Phone Number(Required)

(Include the country code. For example, the US country code is 1.)

Which of these best describes the requestor?

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(Required)

Website

Address(Required)

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.?(Required)

Number of Recipient Facilities

Recipient Country(Required)

Facility #1

Name of Medical Facility to receive assistance(Required)

Type of Medical Facility(Required)

Address(Required)

City State / Province / Region Country

Number of Beds(Required)

Please enter a number greater than or equal to 1.

Number of beds currently in your facility.

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(Required)

Address(Required)

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(Required)

Address(Required)

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:

Final Steps

There are fees associated with the delivery of a cargo container full of medical supplies which are the responsibility of the client. Are funds currently available to pay the Needs Assessment Deposit and Cargo Container fee in full?

Yes, all funds are currently available.

No, all funds are not currently available.

Will your organization be supported with government funding?

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

No, government funding not be used to support this container.

Unclear. We have not yet determined the source of funding, but it may include US government, other government, or UN funding,

Will you need to fundraise for this project?

If fundraising, how long do you anticipate it will take to raise the required funds?

How will the funding be secured to cover the associated costs of a C.U.R.E. Cargo container delivery?

Please describe the current situation at your hospital/clinic and why you are requesting assistance from Project C.U.R.E.(Required)

Please share a few photos of the hospital/clinic:

Drop files here or

Max. file size: 128 MB.

Accepted file types: jpg, gif, png, pdf

Request for Medical Equipment & Supplies

Requestor Information

Organization or Medical Facility Information

Additional Information

Facility #1

Facility #2

Facility #3

Final Steps

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