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Humanitarian

Humanitarian Product Donation Request Form

Thank you for contacting us. Please provide all of the requested information below. This information will be considered in our careful review and evaluation of your request. Include any additional material you feel will support this request, such as your organization’s mission statement on letterhead.

Donation requests should be submitted at least 12 weeks prior to the event start date. Urgent requests will be considered on a case-by-case basis, with no guarantee of a decision made in time to accommodate the delivery of the product by the requested date.

Individual Information

Name of individual requesting assistance: *

Phone Number *

Email Address *

Organization Information

Organization’s Legal Name: *

Street Address: *

City: *

State/Province: *

ZIP/Postal: *

Country: *

Organization's Phone Number: *

Name of Authorized Representative of the Organization: *

Confirmation of tax-exempt/non-profit status from IRS, if applicable

Copy of organization’s W-9 form (US) or comparable non-US tax information document *

Attach additional information:

Humanitarian Mission Details

Target Population: *

Type of Medical Outreach (Needs Assessment): *

Overview of the Sponsoring Agency: *

Trip Start Date *

Trip End Date *

Location of Medical Mission: *

Number of patients expected to be treated: *

A specific list of products/items (quantities required): *

Date product is needed to meet organization's shipping schedule: *

Procedure(s) Expected to be Performed: *

Number of Health Care Providers Participating: *

Experience and Education with the Requested Product/Equipment

Have all anticipated operators/providers received product/equipment education? * Yes No

Who will educate inexperienced users? *

If possible, we are happy to set up an education session with a local representative for your area to ensure everyone is properly educated, as this is imperative to successful treatment. If you would like our assistance with product/equipment education, please provide the following information.

Name of Contact Person: *

Phone Number *

Email Address *

Once we have received all of the necessary information and it has been reviewed, we will notify you if Teleflex will support your request or not. All approved requests will be processed as soon as possible.

Please enter your email here to verify proper submission *

If you do not receive a confirmation email upon submitting your request, please reach out to Humanitarian.Donation@teleflex.com.

Mail to:
Teleflex Medical
Humanitarian Program Coordinator
118 Broadway Street, Suite 227
San Antonio, TX 78205

Fax: +1-919-328-1396
Email: Humanitarian.Donation@teleflex.com

Please include a signed Letter of Request on the requesting organization’s letterhead that includes the following detail:

The Organization’s legal name, address, and phone number
Contact information for authorized representative of the organization
Type of medical outreach
Overview of the sponsoring agency
Dates and location of medical mission
Date product is needed to meet organization’s shipping schedule
A specific list of products/item number(s), quantities required
Number of patients expected to be treated
Procedure(s) expected to be performed
Number of Health Care Providers participating
Experience and education of participating operators/providers with the requested product/equipment:
- Have all anticipated operators/providers received product/equipment education?
- Who will educate inexperienced users?
- Would you like to request an education session with a local representative to ensure operators/providers are properly educated?

Please include:

a copy of organization's W-9 form (US) or comparable non-US tax information document
confirmation of tax-exempt/non-profit status from IRS, if applicable