CONTACT SHIP TO MASTER CARD VISA AMERICAN EXPRESS DISCOVER. Card #: Expiration Date: Card Holder s Name: Security Code:

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1 ACCOUNT MAP Account Name: MEDICAL MISSIONS PACK ORDER FORM MAP International 4700 Glynco Parkway Brunswick, GA Customer Relations: Fax: MAP Account #: CONTACT Name: Phone: Fax: MAP Use TRAVEL TRAVEL DESTINATION City/Region: COUNTRY: MEDICINE/SUPPLIES DESTINATION Hospital/Clinic: SHIP TO Name: Street: City: Order #: Acct #: DEPARTURE DATE: State: ZIP: RETURN DATE: Phone: Payment must accompany your order. Service fee is tax deductible. Packs may not be returned for a refund. Check (note account name on check - if faxing order, include copy of check) TT: Offer #: PAYMENT MASTER CARD VISA AMERICAN EXPRESS DISCOVER Card #: Expiration Date: Card Holder s Name: Security Code: Card Holder s Billing Address: ORDER Service Fee Quantity Service Fee Totals medical missions pack essential+ $400 X = $ medical missions pack Rx medical missions pack otc $200 X = $ $150 X = $ ETA: Ship Date: ***Shipping cost is NOT included in the service fee and will be determined by the MAP Customer Relations Team based upon the shipping address you provide. *** DONATION Any additional donation to help support MAP s medicine programs is very much appreciated. If you wish to contribute, please indicate the extra amount here: $ Thank You!

2 All partners requesting prescription medicines and/or surgical supplies must provide this form, completed and signed by the licensed practitioner whose current state license and DEA numbers are included. By completing and signing this form, the licensed healthcare practitioner assumes full responsibility for medicines and medical supplies provided by MAP International. All medicines and medical supplies are to be used only in mission work outside of the United States of America and in compliance with the U.S. Food, Drug and Cosmetic Act, as amended, and all other applicable U.S. laws and regulations. The practitioner agrees that these medicines and supplies will not be marketed in the United States nor returned to the United States, nor sold or exchanged for property or services. All medicines and medical supplies will be used only in treating the ill, the needy and infants. If these supplies are lost, confiscated, or stolen prior to arriving at their ultimate destination, report the situation immediately to MAP International by phone ( ), fax ( ), or MAP verifies with state medical boards that all license numbers are current. Date: Country where products will be used: Account Number: Account Name: Signature of Ordering Practitioner: Name of Ordering Practitioner: State or Country Issuing Professional License: License Number: Expiration Date: DEA Number: Specialty: Phone: Address: If ordered products are not to be shipped by MAP to the practitioner above, provide the name and address of the authorized recipient: Name: Address:

3 Type of Application (Choose One) Organization or Church Individual Name of organization: Name of primary contact: Name of applicant: Organizational affiliations: Address: City: State: ZIP: Phone: Fax: Have you received and read a copy of MAP International s Eligibility Requirements and Guidelines? Do you have experience in clearing medicine through customs to avoid confiscation or paying duties/taxes? Signature of Agreement for Acceptance and Distribution By signing this statement, the undersigned agrees with MAP International s Mission and Vision statement and all conditions of service as explained in the Eligibility and Guidelines, including, but not limited to, the following: 1. All donated product received from MAP International will be used exclusively in charitable work outside the U.S. and in the designated country only and will not be re-exported either to the U.S. or a third country or transferred in exchange for money, other property or services. Violation of this condition may result in prosecution to the fullest extent of the law and/or civil suit. 2. All non-delivery/non-distribution of product due to damage, customs problems or excess amount will be reported to MAP immediately. 3. All dated medicines and products shipped by MAP must be dispensed prior to their expiration date or destroyed in accordance with the original manufacturer s recommendations and the recipient country s regulations. 4. In case of a product recall, all recipients will adhere to MAP s recall policies and procedures. Yes No Yes No Do you have funding to cover service fees and shipping costs, if applicable? Yes No 5. All MAP partners must immediately report any adverse event potentially related to MAP-supplied medicines, supplies and/or products by calling MAP International at (912) and ing or faxing the completed Adverse Event Report form to TBoatwright@map.org or (912) All recipients of MAP-supplied medicines and medical supplies are required to complete and return the delivery confirmation form and submit distribution and impact reports to MAP, including human-interest stories and photographs. The submitted information including photographs and stories may be used by MAP International, its donors and mission partners to promote MAP International s mission and work around the globe. Photos will remain the property of MAP International, will be shared with MAP donors and will not be provided to other agents or sold for profit. 7. MAP International reserves the right to review continued partnership eligibility based on compliance with reporting requirements and adherence to the stated guidelines. Applicant/Contact Name: Organization Name: Applicant/Contact Signature: Date:

4 This form must be filled out completely for EACH mission trip. MAP International is diligent in following where our medicines/supplies are distributed and how people are being treated and healed. We require details about your upcoming project to enable us to serve you better and share our partnership with others. We expect to receive your Impact Report, including impact stories and photos/video, as soon as you return from your mission trip. Section A: Partner Information Date: Have you received assistance from MAP International before? Yes No If YES, please provide the following: Account Number: Account Name: What type of Request is this? (Check all that apply) Custom Medical Mission Pack Europe Other Team Participants identify the number of the following types of health professionals on this mission team: Physician (MD, DO) Nurse Mid-level provider (PA, NP, Midwife) Pharmacist Other (EMT, Public Health, Med Tech, etc.) Section B: Project Information _ Country: City or Region: Mission Sites please indicate the number and types of sites for the medical mission: Hospital Church Clinic School Mobile Clinic Orphanage Other (please specify) Total targeted population (rounded): Environment: Rural Very Remote Jungle Urban Mountains Other Intended beneficiaries of the medical aid (check all that apply): Infants & Young Children (0-4 yrs) Adults (20-59 yrs) Primary school-age children (5-9 yrs) Elderly (60+ yrs) Adolescents (10-19 yrs) Page 1 MAP International GEMS Project Information Form

5 Percent of population living on less than $2 per day: 0-25% 51-75% 26-50% % Access to medical care (check all that apply): None Regional clinic Mission Hospital Community Clinic Government Hospital Other Main Health Issues in the project area (check all that apply): Chronic diseases (diabetes, hypertension, asthma, cancer, etc.) Vaccine-preventable diseases (pertussis, yellow fever, hepatitis A, meningitis, etc.) Infectious diseases (HIV, TB, leprosy, etc.) Vector-borne diseases (malaria, dengue, etc.) Parasitic infections (worms, etc.) Malnutrition/Nutritional deficiencies Diarrheal diseases Trauma/Wound care Acute respiratory infections Other: Does the community have access to potable water? Yes No Does the community have access to refrigeration? Yes No Briefly describe the history of your work in this community/country and your goal for this particular mission trip: Main activities of this particular medical mission (check all that apply): Primary care/health screening Disaster relief/refugee care Training of health care workers Community health education Surgeries Pharmacy Dental care Other List both agencies and individuals that you will be working with in the country where the products will be used: Section C: Medicines and Supplies Transportation and Storage Plan How will donated medicines and supplies be transported from the US? Air freight Hand carry as baggage Other Have you complied with all US export license requirements, if any? Yes No Where will medicines and supplies be stored after arrival at the mission site? Secured with mission team Locked pharmacy Other Section D: Medicines and Supplies Distribution Plan Give the name and qualification of the health professional who will be responsible for prescribing any prescription medicines and/or surgical supplies during this mission: Page 2 MAP International GEMS Project Information Form

6 Describe how the medicines and supplies will be handled and distributed in the country of destination: Will only be handled and dispensed by the mission team on this trip. Will be handed over to licensed facilities and/or health professionals for ongoing healthcare. Other explain: How will instructions be given to patients? (check all that apply): Oral Written Pictorial Since unused medicines and supplies cannot be brought back into the U.S., where will unused medicines and/or supplies be stored and how will they be used? (check all that apply): Donated to a licensed healthcare facility and/or health professional for ongoing healthcare. Properly stored by local organization for future medical missions. Disposed according to local governmental requirements when past expiration date. Other explain: Section E: Mission Preparation Have you recruited a translator fluent in the language of the people you will serve? Have you obtained prior approval from the Ministry of Health, or other appropriate authority, to provide medical care and bring medicines into the country? Does your preparation for first-time team members include cross-cultural training? Yes No Yes No Yes No Page 3 MAP International GEMS Project Information Form

7 Donee Name: Date: Donee hereby accepts responsibility for export clearance and export license determination requirements with respect to all transactions between MAP International and Donee. Donee or its duly authorized agent in the United States shall be deemed the exporter for purposes of all applicable U.S. laws. This acceptance shall remain in effect until cancelled in writing by Donee and written notification of such cancellation is received by MAP International. Without limiting the foregoing acceptance of export compliance responsibility, Donee agrees to comply with all applicable U.S. economic sanctions and export control laws and regulations, including the U.S. Export Administration Regulations and U.S. Treasury Department economic sanctions regulations. Donee covenants that it shall not -- directly or indirectly -- sell, export, reexport, transfer, provide, donate, divert, loan, lease, consign, or otherwise dispose of any items received from MAP International to or via any person, entity, or destination, or for any use prohibited by the laws or regulations of the United States or any other applicable jurisdiction without obtaining any and all prior governmental authorizations required by law. Notwithstanding any other agreement, neither Donee nor MAP International shall take or refrain from taking any action prohibited or penalized under the laws of the United States or any applicable foreign jurisdiction. Donee s breach of this covenant shall constitute cause for immediate termination of the Agreement between the parties. Donee agrees to indemnify and hold harmless MAP International and its affiliates for Donee s noncompliance with these controls in connection with the items. This covenant and all remedies provided in relation thereto shall survive termination or cancellation of this acceptance of responsibility. To ensure that MAP International has complete records with respect to such transactions, Donee shall, at MAP International s request, provide MAP International with copies of any and all export documents, including export licenses or other bases for export authorization and the Shippers Export Declarations or AES records filed, with respect to any transactions in which Donee has received items from MAP International. [Donee Name] [Signature] [Print Name & Title] [Date]