Grant Application for Humanitarian Aid Product Donations

Please complete this form in order to upload your completed Grant Application for Humanitarian Aid Product Donations form document.

Important Information:

  • All product donation requests for humanitarian aid must include a completed Product Description Proposal.
  • Grant applications must be submitted AT LEAST 60 BUSINESS DAYS prior to a procedure and/or departure of a humanitarian aid mission via the online submission page below.
  • Any questions regarding this Grant Application should be directed to Acumed’s Grants Committee at grants@acumed.net.
  • If approved by Acumed, the Application Organization may be provided a separate donation agreement that will become a binding agreement between Acumed and the Applicant Organization. Acumed’s receipt of a fully executed donation agreement may be required prior to products being released by Acumed.

Contact Information

Applicant Organization Information

Donation Information

Shipping Information

Required Attachments

The following file formats are allowed: .pdf, .doc, .docx, rtf, odf
The undersigned hereby certifies the following:
· I have the requisite authority to submit this Grant Application on behalf of the Applicant Organization.
· I certify that any donated products by Acumed and listed in the Product Description Proposal are non‐saleable items for use by the Applicant Organization for non‐profit, charitable, and humanitarian aid purposes only.
· All information provided on this Grant Application and attachments are true and correct.
· It is understood and agreed that neither this Grant Application nor the acceptance of donated products creates any obligation on the part of any person or entity to purchase, prescribe, order or otherwise make use of (or arrange for or recommend the use of) Acumed’s products.
· I acknowledge that any products donated by Acumed are subject to the United States Export Control Laws and may be subject to export licensing requirements. Applicant Organization agrees to comply strictly with all such laws and regulations and is responsible for obtaining such licenses to export and/or re‐export the products donated by Acumed.
· If this Grant Application is approved by Acumed, I acknowledge and understand that an individual with the requisite authority from the Applicant Organization may be provided a separate donation agreement that will become a binding agreement between Acumed and the Applicant Organization. I acknowledge and understand that Acumed’s receipt of the fully executed donation agreement may be required prior to any products being released by Acumed.