US ER GIFT IN KIND AGREEMENT PACKAGE

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To Complete:
Please complete all required questions/fields (designated by " * " before the question). Note that the system will not allow you to move forward to the next page if a required question/field is not completed. To toggle to other pages, you should select the drop down box in the right hand section of your screen and/or use the arrows. DO NOT USE the back browser arrow.

Contents:
Page 1: Organization, Contact & Shipping Information (required)
Page 2: Medical Professional Agreement of Responsibility (required if receiving medical product donations)
Page 3: Partnership Agreement (required, needs - signature)

* Organization / Facility Description:

Organization Address & Contact Information:

Primary Contact Information:

Preferred Shipping Information:

Please complete the information below for your preferred shipping address. You will also be asked for an alternate shipping address below (if any).

Secondary Shipping Information:

Please complete the information if you have a secondary/alternative shipping address to the one above.

*Will you be receiving any medical product donations?

If YES, you will be asked to complete additional information. If NO, you will move onto the Agreement section.

Click button below to go to the next section. Do not hit the back browser arrow.