Providence Health International
Medical Supply Request Application

____________________________________________

Please note:  Providence Health International (PHI) is committed to providing quality donations that are appropriate for the settings where they will be used.  While there are no charges for the materials themselves, financial donations to help off-set costs associated with rent, labor, utilities, etc. are greatly appreciated.  PHI’s average cost to prepare and shipp one pound of needed supplies is a little less than $2.00 a pound.  Thank you for whatever support you can provide.  Checks should be made payable to PHI and mailed to address shown below.

In consideration of PHI's donation of medical supplies and equipment to the applicant, he/she agrees to:

1. Not limit the access, availability or delivery of the supplies and equipment based upon race, religious beliefs or political persuasion. Supplies and equipment have been provided for the exclusive treatment of the poor and underprivileged.

 2. Notify PHI in writing within seven days of your return of the successful delivery of requested supplies and equipment to the destination healthcare facility.  A pre-printed feedback report will be provided for this notification.

 3. Providence Health International with any acknowledgements, photographs or first-hand reports related to the donation, delivery and use of the donated supplies and equipment which might further promote the awareness of international mission needs and thereby encourage volunteerism and product donations. 

 COMPLETED APPLICATIONS SHOULD BE RETURNED TO:

 Providence Health International
Medical Surplus Recovery

2601 WILLAMETTE DRIVE NE, SUITE G

LACEY, WASHINGTONUSA 98516

PHONE: 360-493-5641

FAX: 360-438-0579

 

You may also contact

Kevin.Brown@providence.org

_____________________________


 
Page 1 of 1
 
 
1.
*
 

 

 

 

 

 

 

 
   
2.
*
 

 

 

 

 

 

 

 

 
   
3.
 

 

 

 

 

 

 

 

 
   
4.
 
   
5.
 

 

 

 

 

 
   
6.
*
 
   
7.
 
   
8.
 
   
9.
 
   
1.   
2.   
3.   
4.   
5.   
6.   
7.  
8.  
9.  
10.  
11.  
12.  
   
10.
 

 

 
   
11.
 
   
12.
 
   
13.
 
   
 
 
 
 Done  Save  Cancel   

Copyright © 1997-2011 Providence Health & Services. All rights reserved.