Evaluator Profile

Distribution Partner Application

Mobility Worldwide's Mission Statement: “To reflect the love of Jesus Christ by bringing mobility and dignity to those in developing countries who do not have the ability to walk.” The Mobility cart is to be donated freely as a humanitarian aid effort and must be given away at no cost nor obligation to the physically disabled. The only requirement is that it is needed.
Please respond to all questions in ENGLISH
About You

Please provide your name, address and contact details so we can respond to you in a timely manner:
Name*

First NameLast Name
Title
Address*

Street Address

Street Address Line 2

CityState/Province

Postal/Zip CodeCountry
Email*
example@example.com
Work Phone Number

Country CodeArea CodePhone Number
Mobile Phone Number*

Country CodeArea CodePhone Number
Preferred Phone
Preferred Language
Your Organization:
Organization Name*
Date Established

MonthDayYear
Date
Website
Main Activities:
Mission Statement:
U.S. organizations: Do you have 501(c)(3) status?*

YesNo
International Organizations: Do you have accredited non-profit status in your country of operation?'

YesNo
Upload Non-Profit Status Document

Cancelof
Partner Affiliations: Religious, Governmental, Corporate, Non-Governmental Organization. Other groups you are connected to and work with in country partnerships:
Logistical Concerns:
Available staff and volunteers – The units need to be assembled (20 minutes per unit). Can you gather volunteers for assembly?

YesNo
Transportation – Do you have access to transportation (large trucks) to move the boxed or assembled units for delivery or storage in you area?

YesNo
Storage: Do you have a temporary storage area for the units until they can be put together and distributed?

YesNo
Import: Do you have the logistical structure and necessary permissions to import a cargo container?

YesNo
Assessment and Distribution:

Mobility Worldwide seeks photos, videos and stories about cart recipients. Please maintain contact with us so that we can share the gift of mobility with our volunteers, sponsors and friends.
Please describe your organization's current monitoring and evaluation framework.
Can you also describe in detail how you plan to assess the physical disabilities of the recipients?
Do you have any medical doctors or physical therapists that would be part of your assessment team?

YesNo
If you or your organization does not have the capacity to adequately assess and distribute the Mobility Carts, are you willing to enter into a cooperative agreement or Memorandum of Understanding with another local organization to accomplish this?

YesNo
Please tell us the number of Mobility Carts that are needed by your organization. A 40’ HC shipping container will hold an estimated 187 to 228 carts, depending on boxing and cart types. We provide Large, Small and Pull carts. Shipping by truck, we can send 1-187; again this varies by which cart types are to be shipped. 7 large carts to a pallet. 10 small carts to a pallet. 7 pull carts to a pallet.
Can you provide a time frame for distribution?

YesNo
Please enter the planned distribution date:

MonthDayYear
Date
Transportation Funding
Your organization must be able to obtain funding, private or government grants, or corporate sponsorships for the transportation of the Mobility Carts to your field location. All costs related to ocean and inland freight charges are the responsibility of the Mobility Worldwide distribution partner. Mobility Worldwide is not responsible for any collect carrier fees, port fees, import customs clearance, agency fees, or local trucking. Any of these potential costs must be taken into account by our distribution partners.

YesNo
Contact information from 5 organizations (preferably in the US) that your organization has worked with. Please include name, organization/company name, address, phone number and email.
Application Date*

MonthDayYear
Date
Should be Empty:

Distribution Partner Application

About You

Your Organization:

Logistical Concerns:

Assessment and Distribution:

Transportation Funding