| 1.
Name of requesting institution (ministry, foundation, etc.): |
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| Name of requesting institution: |
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Contact Person and Title:
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2.
Address of requesting institution:
Please state physical address as well as mailing P.O. Box Address |
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| Number and
Street |
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| City, State: |
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| P.O. Box,
Mailing Address |
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| Telephone/Fax: |
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| E-Mail: |
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| Physical Delivery Address |
| Physical Delivery
Address if different from the above: This is required for Customs
purposes and shipments can not occur without this information. |
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| Institutional
name: |
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| Number and
Street |
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| City, State: |
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| P.O. Box,
Country |
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| Telephone/Fax: |
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| E-Mail: |
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| 3.
Representative or Contact Person in USA or Canada, if any: |
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| Name and Title |
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| Street and Number: |
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| City, State: |
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| P.O. Box, ZIP: |
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| Phone/Fax: |
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| E-Mail: |
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| 4. Desired port of
entry: |
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| 5.
Customs Broker name: |
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| Name of Customs broker: |
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| Address: |
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| Phone/Fax: |
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| E-Mail: |
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| 6.
General Community Description |
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| Description |
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| Total
community population served: |
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| Population
under 15 years |
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| Population
over 60 years |
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| Women of child
bearing age |
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| Average annual
income (USD) |
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| 7. The equipment will be used
to: |
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| 8. Describe the legal status of
the institution. |
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| 9.
Current Institutional Characteristics: |
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| General
Medical Care: |
InpatientOutpatient |
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| Surgical Care: |
InpatientOutpatient |
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| Specialized
Care: |
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| Please list
the primary diseases or conditions that you address: |
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| 10. Is
your organization connected with the Ministry of Health in relation to its
programs? |
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| 11.
The institution (or sponsor) is able to provide the following: |
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A
donation to cover costs of inland transportation, inspection, testing,
repair, storage, export packing, ocean freight shipping. |
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On-site
equipment installation and personnel training. |
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Maintenance
of equipment. |
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| 12. How will AMRF donated
medical equipment help your facility and the people that you server?
Please describe what problem will be addressed by the AMRF donated
equipment and the reasons for your request. Please state how wit
will be used, who will use it, and who will benefit from it. |
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| 13.
Technical Specifications and Restrictions |
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| Limits on size
of equipment, if any |
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| Limits on
weight of equipment, if any: |
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| Electricity:Volts |
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| Electricity:Cycles |
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| Availability
of electricity: |
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| Electricity reliability: |
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| 14.
Physical and Personnel Characteristics of the institution: |
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| Building: Size
in square meters: |
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| Building
material: |
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| Total number
of beds: |
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| Number of
emergency beds: |
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| Number of
bassinets and cribs: |
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| Number of
incubators: |
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| Total number
of employees: |
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| Number of
Engineers, Equipment Technicians |
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| Number of
Doctors |
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| Number of
Dentists |
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| Number of
Nurses |
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| Number of
Dieticians |
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| Number of
Pharmacists |
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| 15.
Please tell us whether the institution needs technical assistance and/or
training of personnel in the following fields: |
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| Equipment
Installation |
Technical Assistance Training |
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| Use of
equipment |
Technical Assistance Training |
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| Equipment
Maintenance |
Technical Assistance Training |
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| Other specify |
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| YOUR
NEEDS AND DONATED EQUIPMENT |
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| The equipment
supplied is used but has been tested and is functional. It has not
been repainted, refurbished or re-manufactured. There may be dents,
scratches and normal wear visible on the equipment. Please not that
such items as x-ray, beds, and OR tables are often more than 10 years old
but in good working condition. For reasons of infection control AMRF
cannot ship used mattresses with any beds. Mattresses generally are
provided with gurneys and stretchers. Goods are strictly forbidden
for resale. |
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| 16
Are there any age restrictions as to how old a device can be? |
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| 17.Are there any items that cannot
be shipped, such as clothing, furniture, or similar items? |
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| The following list is
organized by medical practice area and lists those items generally donated
and available; AMRF cannot guarantee that they will be available when your
request is being filled. If certain items that you require are not
on this list, please add them under the "Other" within a
category and we will do our best in providing them to you. Please
list how many you request in the Quantity Needed column. |