International Program- Application A: International Shipments

International Container Shipment

Application A

Thank you for your interest in our international shipping program. This letter will provide very important information to help you understand and expedite World Medical Relief’s (WMR) application process.

1. If a question does not apply, please explain why. Any unanswered questions or lack of documentation may result in the return of the application or denial of the request. When necessary, you may add pages to complete an answer, making reference to the question number.

2. Everything must be in ENGLISH. We do not provide translation.

3.There must be a contact person who is responsible for working with our personnel including making arrangements for the shipment.

Once the completed application is received our Distribution Committee will review it. You will be notified of the approval or denial. The Director of International Programs will arrange with your contact person for the details and date of shipment.

The following list identifies the various costs associated with the shipment:

1. WMR’s handling fee, which is identified on the last page of this package. If your

application is approved, it must be paid prior to the shipment.

2.The shipping company’s fee. You or your contact person will be responsible for paying this fee directly to the shipping company. WMR will not be involved in that transaction.

3. A charge of $250 per week may be assessed if we are required to hold the container until an inspector approves the shipment. 4. A $100 packing fee may be assessed if we have to repack the pallet/gaylord boxes.

We look forward to possibly working with your organization and we hope that these guidelines assist you in completing the application. If you have any questions please give us a call.

Sincerely,

George V. Samson President & CEO

World Medical Relief

Container Shipment Application
ATTENTION: Please be aware that at times the Preview PDF displaying your progress may not always render correctly- particularly if the form is not yet fully completed. Once your submission is successful, you will have the option to “Edit,” “Submit another form application,” and download the official PDF with your responses.

Always save your progress using the “Save” button above to avoid losing any information while completing this form.
- Name of Recipient
- A. Legal address of recipient
- Street
- City
- Province
- State
- Country
- B. Type of Institution (Please Specify)
  
  Other
- C. Legal Status of the Institution
- D. Name and license number of chief medical or dental officer
- Name
- ID #
- Address
- City, State, Province, Country
- Telephone (country code/area code & number)
- E-mail address (if available)
  example@example.com
- E. Name and title of individual or person in charge of the recipient organization:
- Name
- Address
- City, State, Province, Country
- Telephone (country code/area code & number)
- E-mail address (if available)
  example@example.com
- F. The locality for the request is:
  
  Other
- G. Are services provided to the community free of charge?
- If the answer above is “no”, please explain what is paid and how this cost is determined (Write 'N/A' if not applicable)
- H. Electricity – Is there any available?
- If yes, VOLTAGE (Write 'N/A' if not applicable)
- CYCLES (Write 'N/A' if not applicable)
- The electrical equipment we usually supply is 110 volts. Recipients will
  
  be responsible for voltage conversion, if any.
- 2. Please indicate the ten (10) leading cases diagnosed in the facility:
- 1.
- 2.
- 3.
- 4.
- 5.
- 6.
- 7.
- 8.
- 9.
- 10.
- 3. The Following Documentation Is Required In Order For This Application To Be Processed:
- A. Copy of the Certificate of Registration or proof as a recognized health facility or state on a separate paper if this is not a requirement of the country.
  
  Cancelof
- B. Customs Duty Exemption or Letter of Responsibility of Fees Agreement (See attached sample of Letter of Responsibility)
  
  Cancelof
- C. Copy of license/diploma of the physician in charge of the Institution
  
  Cancelof
- 4. List Of Needs: Please provide a separate list of the recipient’s needs – not WMR’s list of available items. WE MAY NOT BE ABLE TO SUPPLY ALL THE ITEMS YOU REQUEST. WE RESERVE THE RIGHT TO DELETE, SUBSTITUTE OR ADD ITEMS. PLEASE BE AS SPECIFIC AS POSSIBLE WHEN LISTING MEDICAL EQUIPMENT.
- 5. Description Of Your Facility Or Program. If this request is for more than 1 hospital/clinic, please attach a separate sheet to answer parts "b" and "c" for each hospital/clinic
- 1. Is this request for a hospital?
- a.) How many hospitals?
- b.) List the name and address for each hospital and administrator.
- c.) Total number of beds in the hospital
- 1. Is this request for a clinic?
- a.) How many clinics?
- b.) List the name and address for each clinic and administrator.
- c.) Total number of beds in the clinic
- Please indicate how you came to know about World Medical Relief. Please give the name, address, and telephone number with area code, of person or organization who referred you to World Medical Relief.
- WORLD MEDICAL RELIEF, INCORPORATED
  
  POLICY FOR DISTRIBUTION OF DRUGS, MEDICAL SUPPLIES AND EQUIPMENT
- World Medical Relief operates exclusively for charitable purposes, through the receipt of contributions of cash and other properties, including medical and dental supplies, equipment, instruments and pharmaceuticals; and through the purchase of such items when required. It distributes these items in developing countries for the benefit and relief of financially impoverished persons throughout the world in a nondiscriminatory fashion without regard to geography, race, color, creed, gender, age, nationality or political beliefs.
  
  1.United States National and Foreign Programs:
  
  A.World Medical Relief shall distribute pharmaceuticals to approved non-profit organizations who distribute such items under the direction of licensed civilian doctors to financially impoverished persons.
  
  B.World Medical Relief shall distribute medical and dental supplies and/or equipment to approved non- profit organizations who distribute such items under the direction licensed civilian doctors, nurses or paramedics to financially impoverished persons.
  
  C.World Medical Relief shall distribute pharmaceuticals, medical supplies and/or equipment to approved non-profit organizations, individuals or groups who agree in writing that such items will be distributed by them in accordance with pharmaceuticals, equipment and supply policies 1.A. and B. of World Medical Relief. Such parties shall furnish written requests for pharmaceuticals, medical and dental supplies, and equipment needed by such parties prior to shipment of same by W.M.R. Following delivery of said items, the party receiving such goods shall send a written receipt to W.M.R.
  
  2. Local Program:
  
  World Medical Relief distributes to the financially impoverished residing in the area serviced by United Way Community Services and other areas approved by the Board of Directors of World Medical Relief within the State of Michigan. Prescriptions, medical equipment, and supplies are given, providing that the individuals residing within such service areas shall meet the requirements set by the Board of Directors of World Medical Relief.
  
  3. General:
  
  A. Shipments: World Medical Relief shall make no shipments for any person or group that has not originated at its warehouse, nor shall World Medical Relief do any crating for any person or group of their items for their shipping.
  
  B.Donation of pharmaceuticals, equipment and supplies: World Medical Relief does not accept any donations of equipment, instruments, supplies, pharmaceuticals or other items that are designated for a specific person or place. All donations as above listed must be unrestricted.
  
  I have read the above policy for distribution of pharmaceuticals, medical supplies and equipment as outlined by World Medical Relief, Inc. and agree to abide by it.
- DATE
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Signature
- TITLE
- This form must be signed by the individual in charge of the recipient organization – not by the sponsor.
- WORLD MEDICAL RELIEF, INC
  
  RELEASE/HOLD HARMLESS/INDEMNIFICATION AGREEMENT
- The undersigned, in consideration of World Medical Relief, Incorporated providing us with supplies, medical equipment and other medical support, agree:
  
  1. To release World Medical Relief, Inc. from any and all claims made against the undersigned, as a result of the use, misuse or any application of the product or services provided by World Medical Relief, Inc.
  
  2. To hold World Medical Relief, Inc. harmless from any and all costs, claims, actions including by not limited to actual attorneys fees, judgments or other claims which may be brought by any party, person(s) or individuals from the use, misuse or any application of the supplies or services provided to the undersigned by World Medical Relief, Inc.
  
  3. To indemnify in full, including all attorneys fees, expenses, out of pocket costs and other costs of any kind, type or nature which World Medical Relief, Inc. may become liable for as a result of the undersigned’s use, misuse or application of any kind, type or nature for the services or supplies provided to the undersigned by World Medical Relief, Inc.
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Signature
- Print Name
- Title or Position
- **NOTE: This form must be signed by the person in charge of the recipient organization – not by the sponsor.**
- WORLD MEDICAL RELIEF, INC
  
  OBLIGATIONS OF THE RECIPIENT INSTITUTION
- A. To confirm the inventory of the donation by signing the DONATION- ACKNOWLEDGEMENT FORM which is included in the shipping documents. This form to be returned to WMR within one month.
  
  B.To share with WMR any photographs or press releases which might promote future
  
  program activities. In addition, we may require pictures of the facilities during operating hours.
  
  C. To inform World Medical Relief of the condition of the shipment, i.e. any damage or
  
  missing items within one month of receipt.
  
  D. To receive representatives of WMR who will verify the condition and/or use of the
  
  donated equipment and supplies.
  
  E. To recognize that the items requested are for charity use only and are not to be sold or
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Signature
- Please Print Name
- Title or Position
- IF AN ORGANIZATION IS UNABLE TO COMPLY WITH THE OBLIGATIONS LISTED ABOVE, ASSISTANCE TO THEM MAY BE TERMINATED AS A RESULT.
  
  **NOTE: This form must be signed by the person in charge of the recipient organization – not by the sponsor.**
- WORLD MEDICAL RELIEF, INC
  
  SPONSORING INSTITUTION/INDIVIDUAL
- 1. Name Of Sponsoring Institution/Individual
- A. Legal address of sponsoring institution/individual
- Street
- City
- Province
- State
- Country
- Telephone # (country code/area code & number)
- E-mail address (if available)
  example@example.com
- B. United States/Canadian Contact Person To Coordinate Shipment:
- Name
- Address
  
  Street
  
  Street Address Line 2
  
  City, State, ZipState / Province
  
  Postal / Zip Code
- Telephone #
- E-mail address
  example@example.com
- 2. The Following Documentation Is Requested Regarding The Sponsoring Organization. (Not Applicable for individuals)
- A. Name of the organization
- B. Contact person/representative
- Address
- Telephone #
- C. If the organization is not a recognized institution or is a newly registered entity, please provide the following:
  
  A. Articles of Incorporation/partnership papers
  
  B. Rules and/or by-laws of organization
  
  C. Copy of tax-exempt status of organization
  
  D. List of Board Members with their business affiliations
  
  3. Shipping Arrangements – After approval, your United States/Canadian contact person will be required to make shipping arrangements with World Medical Relief and a designated freight forwarder. No other freight forwarder can be used aside from WMR's approved designated steamship line.
  
  4. Payment of costs. A letter MUST ACCOMPANY THIS APPLICATION from the individual or organization stating responsibility for shipping costs and World Medical Relief’s service fees. All service fees must be paid to WMR and shipping charges directly to the designated freighter company prior to shipping.
  
  5. A detailed packing list/documentation will be forwarded to the United States/Canadian contact person after the loading of each container.
- MEDICAL SUPPLIES BY CATEGORY
- SERVICE FEES FOR INTERNATIONAL SHIPMENTS (APPROVED APPLICATION "A" ONLY)
- SERVICE FEES FOR INTERNATIONAL SHIPMENTS
  
  (APPROVED APPLICATION "A" ONLY)
  
  40 Foot Container $12,000
  
  20 Foot Container $7,500
  
  SERVICE FEES FOR MISSION/LOCAL SHIPMENTS
  (APPROVED APPLICATION "B" AND "C" ONLY)
  
  If the Value is: The charge is:
  $ 100 TO $ 14,999 7%
  $ 15,000 AND above 4%
- The above costs and percentages are subject to revision without notice and do not apply to special medication orders.
- ACKNOWLEDGEMENT FORM
- This is to acknowledge receipt of a shipment of medicine, medical equipment, medical supplies (include any applicable items) on ________
  
  The contents of the shipment coincided with the packing lists received and the shipment arrived in good condition.
  
  (Please use the above information as a format to send an acknowledgement ON YOUR LETTERHEAD to World Medical Relief within 30 days of receiving your shipment. We also require receiving photographs of the items in use at your medical facility.)
  
  If the shipment was damaged in any way or if items seem to be missing, please notify WMR immediately.
  
  NOTE: It is imperative that you send your acknowledgement as soon as you receive your donation. Failure to comply may result in suspension of future donations.
  
  Send Letters To: World Medical Relief, Inc.
  
  Attn: International Program
  
  21725 Melrose Avenue
  
  Southfield, MI 48075
- WORLD MEDICAL RELIEF, INC.
  
  RESPONSIBILITY OF FEES AGREEMENT
- I,
  Representative's Name
- a representative of
  Hospital/Clinic/Org. etc
- with postal address
- ,hereby declare responsibility for a shipment to
  Name of Hospital/ Clinic & Country
- Southfield, Michigan U.S.A. This responsibility extends to all fees involving the shipment (i.e. shipping costs, taxes, custom duties, demurrage fees, etc
  
  In the event the recipient institution is unable to get a tax exemption letter, the undersigned and other officials named in our application to World Medical Relief, Inc. shall take the full responsibility whatever the obligation may occur. We are also aware the donation of medical supplies is intended for charitable purposes only and is not for sale or resale. It is intended for the sick, poor and the needy only.
  
  However, World Medical Relief, Inc. has no obligation in any transaction during the process of releasing the container from customs nor shall World Medical Relief, Inc. retrieve any container sent overseas back to the United States.
- Signed this
  Day i.e 23rd
- day of
  Month
- Year
- Signature
- Printed Name
- Title
- Witness

Reminders Before Submitting

Checklist of Required Attachments
Any unanswered questions or lack of documentation may result in the return of the application or denial of the request. Please confirm each item below before submitting.

Required documentation (Section 3)

❑ A. Copy of the Certificate of Registration or proof as a recognized health facility — or a statement on a separate paper if this is not a requirement of the country.

❑ B. Customs Duty Exemption or Letter of Responsibility of Fees Agreement.

❑ C. Copy of license/diploma of the physician in charge of the Institution.

Also required with the application

❑ List Of Needs (Section 4) — a separate list of the recipient’s needs, not WMR’s list of available items. Be as

specific as possible when listing medical equipment.

❑ Letter stating responsibility for shipping costs and WMR’s service fees (Sponsoring Institution, item 4). THIS MUST ACCOMPANY THIS APPLICATION.

If the sponsoring organization is newly registered or not a recognized institution

Not applicable for individuals.

❑ A. Articles of Incorporation/partnership papers

❑ B. Rules and/or by-laws of organization

❑ C. Copy of tax-exempt status of organization

❑ D. List of Board Members with their business affiliations

Pages requiring signature

Each must be signed by the individual in charge of the recipient organization – not by the sponsor.

❑ Policy For Distribution Of Drugs, Medical Supplies And Equipment

❑ Release/Hold Harmless/Indemnification Agreement

❑ Obligations Of The Recipient Institution

❑ Responsibility Of Fees Agreement — also requires a witness signature

Before sending

❑ Every question is answered. If a question does not apply, explain why.

❑ Everything is in ENGLISH. WMR does not provide translation.

❑ A contact person is named who is responsible for working with our personnel including making arrangements

for the shipment.

World Medical Relief, Inc. · Attn: International Program · 21725 Melrose Avenue, Southfield, MI 48075
Should be Empty:

International Container Shipment

World Medical Relief

D. Name and license number of chief medical or dental officer

WORLD MEDICAL RELIEF, INCORPORATED

WORLD MEDICAL RELIEF, INC

WORLD MEDICAL RELIEF, INC

IF AN ORGANIZATION IS UNABLE TO COMPLY WITH THE OBLIGATIONS LISTED ABOVE, ASSISTANCE TO THEM MAY BE TERMINATED AS A RESULT.

WORLD MEDICAL RELIEF, INC

MEDICAL SUPPLIES BY CATEGORY

SERVICE FEES FOR INTERNATIONAL SHIPMENTS (APPROVED APPLICATION "A" ONLY)

SERVICE FEES FOR INTERNATIONAL SHIPMENTS

(APPROVED APPLICATION "A" ONLY)

SERVICE FEES FOR MISSION/LOCAL SHIPMENTS (APPROVED APPLICATION "B" AND "C" ONLY)

The above costs and percentages are subject to revision without notice and do not apply to special medication orders.

ACKNOWLEDGEMENT FORM

WORLD MEDICAL RELIEF, INC.

Reminders Before Submitting

SERVICE FEES FOR MISSION/LOCAL SHIPMENTS
(APPROVED APPLICATION "B" AND "C" ONLY)