Founded 1988

What is AMRF?

The American Medical Resource Foundation's mission is to imporve health care around the world by donating medical equipment and supplies to hospitals that serve the poor in underdeveloped and developing countries of the world.
Learn More about AMRF

Contact AMRF

AMRF
PO Box 3609
Brockton, MA 02304-3609

(p) 508.580.3301

eMail: victor@amrf.com

Online Application

1. Name of requesting institution (ministry, foundation, etc.):
Name of requesting Institution:
Contact Person & Title:

2. Mailing Address of Requesting institution:
Number and Street Name:
City & State:
P.O. Box, Mailing Address:
Telephone / Fax:
eMail address:

2.1 Physical Address of Requesting institution, if different from the above. This is required for Customs purposes and shipments can not occur without this information:
Institutional Name:
Number and Street Name:
City & State:
P.O. Box, Mailing Address:
Telephone / Fax:
eMail address:

3. Representative or Contact Person in USA or Canada, if any:
Name and Title:
Number and Street Name:
City & State:
P.O. Box, Zip Code:
Telephone / Fax:
eMail address:

4. Desired Port of Entry:
Port of Entry:

5. Customs Broker Information:
Name of Customs Broker:
Number and Street Name:
Telephone / Fax:
eMail address:

6. General Community Description:
Description:
Total population served:
Population under 15 years:
Population Over 60 years:
Women of child bearing age:
Average Annual Income (USD):

7. The Equipment will be used to:
Description:

8. Describe the legal status of the institution:
Description:

9. Current Institutional Characteristics:
General Medical Care:	Inpatient Outpatient
Surgical Care:	Inpatient Outpatient
Specialized Care:



List the Primary diseases or conditions that you address:




10. Is your organization connected with the Ministry of Health in relation to its programs?:
Yes/No:

11. The institution (or Sponsor) is able to provide the following:
	A donation to cover costs of inland transportation, inspection, testing, repair, storage, export packing, ocean freight shipping.
	On-Site equipment installation and personnel training.
	Maintenance of Equipment.

12. How will AMRF donated medical equipment help your facility and the people that you serve? Please describe what problem will be addressed by the AMRF donated equipment and the reasons for your request. Please state who it will be used, who will use it, and who will benefit from it.:


13. Technical Specifications and Restrictions:
Limits on size of equipment:
Limits on weight of equipment:
Electricity: Volts:
Electricity: Cycles:
Availability of electricity:
Electricity Reliability:

14. Physical and Personnel Characteristics of the institution:
Building: Size in square meters:
Building material:
Total number of beds:
Number of Emergency Beds:
Number of bassinets and cribs:
Number of incubators:
Total Number of Employees:
Number of Engineers, Equipment Technicians:
Number of Doctors:
Number of Dentists:
Number of Nurses:
Number of Dieticians:
Number of Pharmacists:

15. Please check if the institution needs technical assistance and/or training of personnel in the following fields:
Equipment Installation:	Technical Assistance Training
Use of Equipment:	Technical Assistance Training
Equipment Maintenance:	Technical Assistance Training
Other, Specify:

YOU NEEDS AND DONATED EQUIPMENT
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 note 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 strickly forbidden for resale.

16. Are there any age restrictions as to how old a device can be?


17. Are there any items that cannot be shipped, such as clothing, furniture, or simular itesm?

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 the list, please add them under the "Other (or blanks)" withing a category and we will do our best in providing them to you. Please list how many items you request in the Quantity Needed column.

Please enter how many of each item you need in the Quantity Needed column.
D E N T A L
Dental Chair:
Dental Tower:
Dental Instruments:
Dental X-Ray:



D I A G N O S T I C
Analyzer/Blood Chemistry:
Analyzer/Blood Gas:
Audiometer:
Camera/Gamma:
Centrifuge/Floor:
Centrifuge/Hemocrit:
Centrifuge/Refrigerated:
Centrifuge/Table Top/1 SPD:
Centrifuge/Table Top/Var:
Chloride Meter/Osmometer:
Computer/Cardiac Output:
Counter/Blood Cell:
Cystope:
Doppler/Vascular:
EEG:
Electromyyograph (EMG):
Glucometer:
Heart Rate Det./Fetal:
Lamp/Slit:
Laryngoscope:
Mammography Unit:
Manometer/Aneroid:
Manometer/Mercury:
Meter/pH:
Monitor/CO2/Capnometer:
Monitor/ECG/Heart Rate:
Monitor/ECG/HR/BP:
Monitor/ECG/HR/Respiration:
Monitor/Fetal:
Monitor/Holter:
Monitor/Neonatal:
Monitor/Oxygen:
Pulse Oxymeter:
Recorder/EKG:
Spirometer:
Spirometer/Recording:
Thermometer:
Ultrasound/Abdominal*:
UltraSound/Cardiac*:
Ultrasound/Vascular*:
X-Ray Lamp:
X-Ray View Box:
X-Ray / C-Arm:
X-Ray / Film Processor:
X-Ray / Portable:




I N P A T I E N T
Bassinet:
Bed/Electric:
Bed/Mechanical:
Bed/Pediatric:
Cabinet/Bedside:
Cabinet/Medicine:
Cabinet/Patient Belongings:
Cart/Utility:
Chair/Geriatric:
Chair / Visitor:
Chair/Wheel:
Commode:
Crib:
Crutches (Pairs):
Defibrillator:
Incubator/Neonat Transp:
Lifter/Patient:
IV Pole:
Scale / In-Bed:
Stretcher/Wheeled:
Table/Bedside:
Table/Overbed:
Walker:




L A B O R A T O R Y
Bath/Paraffin:
Culture Media:
Diluter:
Incubator (Lab):
Microscope:
Photometer/Flame:
PIPETER:
PIPETTES:
Scale/Balance:
Shaker:
Spectrophotometer:
Water Bath:




OR
Anesthesia Machine*:
Anesthesia Accessories:
Blood Warmer:
Electrosurgical, Unit:
Hyfricator:
Instruments/Surgical:
Insufflator:
Light/OR/Ceiling:
Light/OR/Mobile:
Monitor/Expired Gas:
Pump/Post-OP:
Sterilizer/ETO:
Sterilizer/Requires Steam:
Sterilizer/Steam/Self-Cont:
Sterilizer/Table-Top:
Surgical Supplies:
Sutures:
Table/Delivery:
Table/Fracture:
Table Oprating*:




O U T P A T I E N T
Cutter/Cast:
Exam Table:
Lamp/Examining:
Opthal/OTO Scope:
Scale/Infant:
Scales/Standup:




S P E C I A L
Bronchoscope*:
ColonScope*:
EndoScope*:
Gastroscope/Esophagoscope*:
Laryngoscope:
Light Source:
Proctoscope*:




S U P P L I E S
Anesthesiology:
Bandages & Dressings:
CardioVascular:
Clinical:
Dental:
Dermatology:
Ear/Nose/Throat:
Emergency Room:
Endocrinology / Metabolism:
Labratory:
Laparoscopic:
Nephrology:
Neurology:
Nutritional:
Obstetrics/Gynecology:
Oncology/Hematology:
Operating Room:
Ophthalmology:
Orthopedic:
Patology:
Pediatric:
Pulmonary:
Radiology:
Rheumatology:
Thoracic:
Urostomy/Ostomy/Colostomy:




S U P P O R T
Books/Medical:
Cart/Food:
Computer:
Freezer:
Printer/Computer:
Refrigerator/Food:
Refrigerator/Blood:
Typewriter:




T H E R A P Y
Ambu Bag:
Concentrator/Oxygen:
Dialysis / Hemo :
Diathermy/RF:
Diathermy/Ultrasound:
Hydroculator:
Hydrotherapy Tub:
Hypo/Hyper Thermia:
Hypothermia/PAD:
IPPB Therapy (Respirator):
IV Pump:
IV Controller:
IV/Syringe Pump:
Lamp/Warning:
Light/BILLI:
Mattress/Air:
Nebulizer/Sprayer:
Nebulizer/Ultrasonic:
Physical Therapy:
Pump/Feeding:
Suction/Tracheal/GOMCO:
Suction/Wall Regulator:
Suction/Wound:
Tourniquet/Automatic:
Traction Frame:
Ventilator/Adult:
Ventilator/Neonate:
Warmer/Infant:




* - These items are no longer available on a donation basis, but we can assist on the purchase of them in the used equipment market and add the cost to the program.
A P P L I C A T I O N C O M P L E T I O N

	This will Erase the Entire Form!
	This will submit the Online Application. You will recieve a notification from AMRF regarding further action.

To date, over $200 million contributions have been made

P.O. Box 3609, Brockton MA 02304-3609 - (p) 508.580.3301