MedShare

Bridging the gap between surplus and need.

Application for Container Shipment From MedShare

(Required) indicates a required field

Please complete this form to request one of MedShare’s 40 foot containers of medical supplies and equipment.

Completing This Application
Shipping the Container
Consignee

This is the organization which appears on official shipping documents as the recipient of the container. In some cases the Consignee is the healthcare institution which will utilize the donated medical supplies. In other cases it is a charitable organization which will receive the container and give the donated medical supplies to a local healthcare institution.

Address EXACTLY AS IT SHOULD APPEAR ON OFFICIAL SHIPPING DOCUMENTS (street, city, state/province, postal code, etc. DO NOT PROVIDE P.O. BOX.)

What is the legal status of this organization?

Is this the healthcare institution which will USE the donated supplies?

Notify Party

This is the person to whom official shipping documents will be mailed via ground courier. This person will use the shipping documents to remove the container from the port.

What is the ocean port where you wish the container to be sent?

MedShare ships the container to the ocean port nearest to the consignee. The consignee is responsible for transporting the container from the port to the hospital(s) where the medical supplies will be used.

MedShare requires the consignees to obtain written permission for duty-free import from the appropriate government agency prior to shipment of the container. Do you currently have permission for duty-free import?

What laws does your country have regarding importation of donated medical supplies and equipment? (Check all that apply.)

The Healthcare Institution

Please describe the hospital(s)/clinic(s) which will use the donated medical supplies and equipment.

What is the legal status of this healthcare institution? (check all that apply)

How many facilities will utilize the items sent in this shipment?

What type of area is this healthcare institution located in?

How is this healthcare institution funded?

Total number of patients treated:

What are the major health problems in this area?

What are the biggest problems this healthcare institution is facing?

How will your patients benefit from the medical supplies and equipment that MedShare sends?

What electrical voltage is used?

How is oxygen delivered?

How are items sterilized?

Is there running water available?

Is there stable electrical current?

Is there internet access?

What medical services are provided at this healthcare institution? (check all that apply)

Please indicate the number of each type of staff position at this healthcare institution:

Other comments about this healthcare institution:

To whom should MedShare email the password for ordering consumable medical supplies online?

What biomedical equipment do you wish to receive for this healthcare institution? (Note: all equipment MedShare receives is donated. Although we make every effort to send you what you ask for, we may not have all the items in stock.)

If your supply voltage is not 110 V/60 Hz, you may need additional transformers to properly operate the equipment you receive. At your request, MedShare can purchase transformers for you for an additional cost.

Funding

MedShare is a non-profit organization and all of the medical supplies and equipment we send are donated. However, we do require funding to cover the cost of operating MedShare and the cost of shipping. The requested amount of funding is $16,000 plus the actual shipping cost in most cases. The contents of a typical MedShare container are valued at $150,000-$200,000!

Please identify the source to provide the funding for this container.

Will the funding be provided by the healthcare institution that will use the supplies?

Recipient Agreement
I, guarantee that the supplies I receive as donations from MedShare International, Inc. will be delivered to to benefit patients in need. I understand that these supplies are donated, have no commercial value, and therefore I will not sell or exchange these items for profit. I further attest that I have read and agree to receive donated items from MedShare according to the stipulations below.

The medical supplies, equipment, materials and other items (“Materials”) available from MedShare International (“MedShare”) are items that would have been discarded or otherwise disposed of by hospitals or health care providers in the United States. These Materials are being made available strictly on an “as is” basis for humanitarian use in circumstances in which sufficient alternative sources of such resources are not available. The recipient organization recognizes that MedShare and the donor facilities do not make any representations or warranties, either express or implied, as to the condition of the Materials, and further recognizes that MedShare and the donor facilities make no representations or warranties, express or implied, that the Materials are fit, appropriate, free from defects, sterile, pure, operable, or otherwise suitable for any intended purpose. The recipient organization accepts the Materials “as is,” with all faults, and acknowledges that the inspection for any defects and the safe operation of said Materials is solely the responsibility of the recipient organization. Each recipient organization, recipient facility, and responsible manager of such entities assumes full responsibility for making an independent determination of the appropriateness of the Materials (or any part thereof) before using them, and for discarding any Materials which are not appropriate for use. Under no circumstances shall MedShare, the manufacturer or distributor of the Materials, or any United States hospital or health care provider that ever owned or used the donated equipment, be liable to recipient organization or anyone for any direct, special, indirect, incidental, or consequential loss or damage resulting from the Materials or their use. To the maximum extent permitted by law, the recipient organization fully accepts and assumes all risks and all responsibility for losses, costs, and damages that the recipient organization, its agents, representatives, members, directors, officers, employees, agents, contractors, patients, and transferees (“Users”) may incur as a result of the Materials or their use, including without limitation personal injuries, illness, damage, loss to property, and death.

MedShare and the recipient organization recognize that this agreement shall release MedShare and the donor facilities from any and all liability for personal injury and/or any other type of injury arising from the use of the Materials. The recipient organization acknowledges that the consideration for this release and indemnification is the donation of the Materials themselves. By making an application for the receipt of such Materials and by accepting such Materials, the recipient organization, to the maximum extent permitted by law, fully releases, acquits, and forever discharges MedShare, the donor facilities, and each and every past and present subsidiary, affiliate, officer, director, agent, servant, employee, trustee, and representative of MedShare and the donor facilities (“Released Persons and Entities”) from any and all loss, damages, claims, causes of action, suits, debts, liens, obligations, liabilities, demands, costs and expenses of any kind, character, or nature whatsoever, known or unknown, fixed or contingent, which might arise from or be related or associated in any way with the Materials or their use, including but not limited to any injury, illness, disease, property damage, death, or loss of any nature suffered or sustained in connection with the use or possession of the Materials. To the maximum extent permitted by law, the recipient organization also agrees to indemnify, save, and hold the Released Persons and Entities harmless for any loss, damages, claims, causes of action, suits, debts, liens, obligations, liabilities, demands, costs and expenses (including attorneys’ fees) of any kind, character, or nature whatsoever, known or unknown, fixed or contingent, which may be incurred arising out of or related to the use or possession of the Materials, regardless of the nature or the extent of the injury, illness, disease, property damage, death, or loss, and regardless of whether it results from the negligence of the Users or of the Released Persons and Entities. Recipient organization agrees to provide MedShare with photos and feedback whenever possible related to how the medical supplies and equipment from this shipment are used. Recipient organization gives MedShare permission to use stories, photos and video related to this shipment for marketing and fundraising purposes.

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