International Program- Application B: Mission Trips

International Mission Trips

Application B
Dear Friend,

Thank you for your interest in our international mission program. This is for the international mission trips with requested items being carried in your luggage or shipping it out through UPS Worldwide Express. In order to be able to process your request we need the following items:
1. The Application for Assistance – completed.
2. A description of the trip – where you are going – when, including date of departure what you will be doing on the trip (e.g. performing surgery on 25 people).
3. List of items you are requesting. If you need items that are not on the attached list, please include them since we might have them in stock at the time of your request.
4. If medicine is being requested: A. if a licensed physician is on the trip we need their name, address, phone number, and a copy of their current license. B. If no physician is on the trip then the medicine MUST be delivered to a doctor in the country and we need their name, address, and a copy of their current license.
5. We need a letter from the person responsible for the World Medical Relief service fee and if applicable, the shipping fee (needed if you are not picking the items up and we have to send it to you or to the recipient country.)
When you return, or after the mission has been accomplished, we will need a report on the mission along with photographs, newspaper articles, etc., within 1 (one) month of your arrival. This is to help us publicize this program as well as verify the legitimacy of the trip/medical mission/special project.

We do hope we can be of assistance to you and will let you know our decision after all of the requested information is received.

Sincerely,

George Samson, Ph.D.

President & CEO

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APPLICATION B – APPLICATION FOR ASSISTANCE

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DATE OF APPLICATION*

MonthDayYear
Date
Applicant’s Name/Title*
Address*
City, State, Zip Code*
Phone #*
E-mail address*
example@example.com
Registration Number*
Copy of License or Diploma of Medical Professional in charge*

Cancelof
Sponsoring Organization of the Mission*
Address*
City, State, Zip Code*
Contact Person’s Phone #*
Fax #*
E-mail address (if available)*
example@example.com
Name of Recipient Hospital or Health Facility*
Address*
City, State or Province, Country*
Physician’s name*
Registration Number*
Copy of License or Diploma of Medical Professional at the Facility*

Cancelof

POLICY FOR DISTRIBUTION OF DRUGS, MEDICAL SUPPLIES, & EQUIPMENT
WORLD MEDICAL RELIEF, INC.

POLICY FOR DISTRIBUTION OF DRUGS, MEDICAL SUPPLIES, & EQUIPMENT

APPLICATION B

Preamble: World Medical Relief, Inc., 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 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:
1. World Medical Relief shall distribute pharmaceuticals to approved non-profit organizations and hospitals/clinics who distribute such items under the direction of licensed civilian doctors to financially impoverished persons.
2. World Medical Relief shall distribute medical and dental supplies and/or equipment to approved non-profit organizations and hospitals/clinics who distribute such items under the direction of licensed civilian doctors, nurses, or paramedics to financially impoverished persons.
3. World Medical Relief shall distribute pharmaceuticals, medical supplies, and/or equipment to approved non-profit organizations and hospitals/clinics, 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 Metro Detroit area and other areas approved by the Board of Directors of World Medical Relief within the State of Michigan. Prescription medications, medical equipment, and supplies are given, providing that the individuals residing within such service areas meet the requirements of the programs. A specified handling fee is applied to medicine supply and equipment ordered.

3. General
1. 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.
2. 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 pacemaker devices, pharmaceuticals, medical supplies, and equipment as outlined by World Medical Relief, Inc. and agree to abide by it.
Date*

MonthDayYear
Date
Print Name/Physician’s Name*
Title or Position*
Signature*

Clear

RELEASE/HOLD HARMLESS/INDEMNIFICATION AGREEMENT
WORLD MEDICAL RELIEF, INC. APPLICATION B

RELEASE/HOLD HARMLESS/INDEMNIFICATION AGREEMENT
The undersigned, in consideration of World Medical Relief, Inc., 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, whether intentional or un-intentional, provided by World Medical Relief, Inc.

(2) To hold World Medical Relief, Inc. harmless from any and all costs, claims, actions including but not limited to actual attorney 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 attorney 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
Date
Print Name/Physician’s Name*
Title or Position*
Signature*

Clear

OBLIGATIONS OF THE RECIPIENT INSTITUTION APPLICATION B
OBLIGATIONS OF THE RECIPIENT INSTITUTION APPLICATION B
A. To confirm the inventory of the donation by signing the DONATION- ACKNOWLEDGEMENT FORM which is included in the shipping documents. This form is to be returned to WMR within one month after reception of medical/dental supplies, equipment, instruments, or pharmaceuticals.

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.

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 bartered.

F. Payment of costs. A letter MUST ACCOMPANY THIS APPLICATION form.

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 shipping company prior to shipping.
Print Name/Physician’s Name*
Date*

MonthDayYear
Date
Title or Position*
Signature*

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

INSTRUMENTS & SUPPLIES FOR ONE OUT PATIENT CLINIC APPLICATION
INSTRUMENTS & SUPPLIES FOR ONE OUT PATIENT CLINIC APPLICATION

RESPONSIBILITY OF FEES AGREEMENT
WORLD MEDICAL RELIEF, INC.

RESPONSIBILITY OF FEES AGREEMENT
I,*
Name
, a representative of*
with a postal address*
, hereby declare responsibility for a shipment to*
Name of Hospital/Clinic & Country
from World Medical Relief, Inc. in 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 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 i.e December
Year*
Signature*

Clear
Print Name*
Title*
Witness*
**Note: World Medical Relief offers special medicine with a special discount price and long- dated medicines as requested**

Please note that WMR’s medications are donated medicines. You will find different kinds in each category. We cannot provide particular medicine by volume; however, World Medical Relief offers “special request medicine” with a special discount price with long dating as requested. This medicine is purchased from a company that supports our International Medical Missions Program. The costs are the special discounted price plus WMR’s service fee (see charges below

SAMPLE LIST OF SPECIAL MEDICINE BY VOLUME:
SAMPLE LIST OF SPECIAL MEDICINE BY VOLUME:
WORLD MEDICAL RELIEF, INC. APPLICATION B

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

If the value is: $100 to $14,999, the CHARGE IS 7-10%

If the value is: $14,000 AND above, the CHARGE IS 4%

The above costs and percentages are subject to revision without notice and do not apply to special medication orders.
Medication Wish List*
Include Specific Medications + Quantity
Supplies & Equipment*
Include Specific Supplies & Equipment + Quantity + Size
Should be Empty:

International Mission Trips

APPLICATION B – APPLICATION FOR ASSISTANCE

WORLD MEDICAL RELIEF, INC. APPLICATION B

OBLIGATIONS OF THE RECIPIENT INSTITUTION APPLICATION B

INSTRUMENTS & SUPPLIES FOR ONE OUT PATIENT CLINIC APPLICATION

WORLD MEDICAL RELIEF, INC.

SAMPLE LIST OF SPECIAL MEDICINE BY VOLUME: