Grantee Last Name:*

Grantee First Name:*

Title:*

Organization Name:*

Address 1:* The shipping address must match the address listed on the medical license in order to receive medical box.

Address 2:

Postal/ Zip Code:

Province/ Region/ State:

City:*

Country:*

Website:

FAX:

Phone:*

E-mail Address:*

Please provide an institutional/organizational reference or a professional reference from outside organization.*

Please provide information about the license type: (MD, DDS, APRN, etc.)*

Please describe about the project and its objectives and what services will be provided?*

Mission Date:*

Please indicate the date you would like your medical box shipped by:*

Duration of project:*

Describe the project location(s) and why was the particular location(s) chosen?*

Did organization conduct an assessment for the project?*

Please describe the target community and its health needs.*

Please describe the expected number of patients to be treated through the project.*

How many health care workers and professionals are expected to take part in the project?*

Please briefly describe which medicines, medical equipment and supplies will be needed for the project?*

Please describe expected results and Impact of the project.*

Please describe the planned methodology for measuring project success.*

Organization Name, Title and Employer:*

Phone:*

E-mail Address:*

Is international shipping required from Pakistan?*

Other documents:

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