Medical Supply Request - Container Shipment

Thank you for contacting Partners for World Health (PWH) to fulfill your request for medical supplies and equipment on a 40-ft container shipment. The PWH Container Program provides a wide range of medical supplies, machines and equipment to a facility or healthcare organizations in need. Fees associated with the container of supplies offset the expenses associated with collecting, sorting and storing the supplies. Shipping costs are passed directly to the customer or the customer may arrange shipping on their own.

Please take a few minutes to carefully complete this form. This will help us serve you more effectively and efficiently! Someone will contact you regarding your request within 3-5 business days.

Basic Information

Tell us about yourself.

First name*

Last name*

Suffix

Email*

Phone number*

Name of the Medical Facility/Organization you represent*

Your Title at Medical Facility/Organization you represent*

Consignee Information

Complete this section carefully. The details will be used to arrange shipment and estimate costs from our headquarters in Portland, Maine, USA to the final destination.

Official Name of the Consignee*

This is the name of the locally-registered LEGAL ENTITY that will appear on the official shipping documents and who will be financially responsible for the receipt of the shipment

Tax ID Number of the Consignee*

Consignee must be a legal entity with locally-registered Tax ID Number

Full Name of the Consignee Primary Contact*

This is the name of the INDIVIDUAL that will appear on the official shipping documents and who will be the primary contact for receipt of the shipment

Mailing Address of the Consignee Primary Contact*

This is the mailing address of the INDIVIDUAL/ORGANIZATION to receive the physical copy of the Consignee Package (Bill of Lading)

Email Address of the Consignee Primary Contact*

This is the INDIVIDUAL that will appear on the official shipping documents and who will be the primary contact for receipt of the shipment

Phone Number of the Consignee Primary Contact*

This is the INDIVIDUAL that will appear on the official shipping documents and who will be the primary contact for receipt of the shipment

Shipment Terms

Complete this section carefully; it will determine how freight logistics are arranged and may result in additional time needed for shipment if responses are updated later in the process.

Preferred Incoterms*

Indicate the preferred terms for freight forwarding of this shipment
*NOTE: All customs duties and taxes assessed at destination port are always the sole responsibility of the consignee

Door to Door freight WITH clearing assistance at port of destination (freight forwarder assigns Clearing Agent and arranges for onward trucking to final destination)

Door to Door freight WITHOUT clearing assistance at port of destination (consignee assigns their own Clearing Agent but freight forwarder arranges for onward trucking to final destination)

Door to Port freight WITHOUT clearing assistance or last-mile delivery (consignee arranges clearing and onward trucking delivery to final destination)

Consignee or Partner arranges all freight from PWH warehouse to final destination

Does your organization work with a Clearing Agent at the port of destination?*

Clearing Agents are required to work with Customs at the port of entry; if you're not sure, select 'NO - please assign one'

Clearing Agent/Notify Party Information

If "Yes - we have our own to assign this shipment" to the question above, please provide contact information for Clearing Agent

Port name/city, country where the container will arrive first*

This may not be the final destination of the container, but the port of entry to land

PWH recommends all inland destination partners purchase the shipping container to avoid additional charges for delays returning it to port, allowing for the container to be used as storage or any utility needed at your facility. There is an additional cost for purchasing the container, which will be shared prior to booking and you may opt out of purchasing at that time.

Check here if interested in purchasing the shipping container

Container Loading Requirements*

PWH "loose loads" containers (filling entire container from floor to ceiling with cargo) by default; please confirm the loose load option or opt for palletized cargo according to the needs and requirements of the final destination transportation.

Final Destination & Beneficiary Information

Complete this section carefully; responses will determine whether or not PWH can support the shipment as requested. PWH reserves the right to decline shipment requests if the work of the receiving facility or organization does not align with PWH's mission.

Official Name of the Recipient Organization or Facility of the final destination*

Note this MAY be the same as the Official Name of the Consignee, above. Even if the container is only delivered to the Port per the incoterms above, please list the name of the final destination beneficiary/recipient facility

Address of the Organization or Facility (this is the final destination of the shipment's contents) *

Address Line 1*

Address Line 2*

City*

State/Region/Province*

ZIP/Postal code*

Country*

Legal Status of the Recipient Organization/Facility*

Other Legal Status

If 'Other' selected above, please describe the Legal Status of the Recipient Organization/Facility

If your Organization/Facility will collect the goods and distribute them among a network or multiple collaborating organizations, select Yes.

Check here if the goods will be distributed beyond the Consignee Organization or Facility

How is the Medical Facility/Organization funded?*

Fee for Service

Government

Charitable Funds

Other

Other Funding Status

If 'Other' selected above, please describe how the Medical Facility/Organization is funded

Catchment Population*

What is the estimated total Catchment Population (health service area) of the facility/organization receiving this shipment?

Mission Impact*

PWH's mission is to provide access to high quality medical care in under-resourced communities. How will this shipment support our mission? Please elaborate.

Import Information

Complete this section carefully; it will determine how the container contents are prepared and may result in additional time needed for shipment if responses are updated later in the process.

Does the destination country allow import of expired medical supplies and equipment?*

Supplies must expire within __ months of arrival

If "No, supplies must expire within -- months of arrival" selected above, how many months?

Does the destination country require pre-inspection of medical supplies and equipment to be imported? *

Pre-inspection requirements

If a pre-inspection is required for this shipment, please describe the process

Does the destination country restrict the importation of "refurbished" or "used" goods?*

Restrictions for Used Goods

If "Yes, the restrictions are" selected above, please describe the restrictions against "refurbished" or "used" goods

What paperwork does the destination country need in order to approve the shipment PRIOR to loading? **

Is there anything else PWH needs to know regarding the destination country's import regulations?*

Additional Questions

Desired Date of Shipment*

Month/Day/Year

Who will fill out the required, subsequent Healthcare Facility Assessment Form and Inventory Request list? (These forms will be sent to you upon submission and acknowledgement of this form.)*

Person's name, email address and title

Required Affirmation:

I, the individual completing this form guarantees that the supplies received from Partners for World Health will be administered by the medical professional listed above or by others under that person's direction for the benefit of those served by the institution above. I, the individual completing this form understands that these supplies are donated and as such have no commercial value and that the items are not to be sold, resold, or exchanged for profit or gain. I further attest that I have read and agree to receive donated items from Partners for World Health according to the pre-disclosed stipulations.*

I understand and agree to the above statement*