| POTENTIAL NEW DISTRIBUTION PARTNER APPLICATION |
| Please fill the below out to your best ability. If a question does not apply to your organization, please write N/A (not applicable). |
| HOW DID YOU HEAR ABOUT FWM? | |
| 1. ORGANIZATION (* indicates required field) |
| a. Organization Name * | |
| b. Name of person filling out the application. * | |
| c. Address * | |
| d. Phone * | |
| e. Website * | |
| f. Email address * | |
| g. Skype ID | |
| h. Country you would like to serve * |
If the country you are serving in is not listed, we have either reached our maximum capacity for partners there and/ or we cannot ship there due to logistical challenges. |
2. HISTORY OF YOUR ORGANIZATION |
| a. Year founded | |
| b. Main activities | |
| c. Description of your programs | |
| d. 501(c)(3)? | Yes No |
| If yes, attach a copy of the front page of your 501(c)(3) here or fax to our office at 949-273-8471. Max file size 100kb |
| | Browse to your pdf and upload here. Upload Clear |
| 3. AFFILIATIONS |
| a. Government groups | |
| b. Religious groups | |
| c. Corporations and for-profit groups | |
| d. Non-Government Organizations and not-for-profit groups | |
| e. Other groups you are connected to and work with in partnership | |
| 4. MISSION STATEMENT - Why does your organization exist? What are you trying to accomplish? | |
| 5. AVAILABLE STAFF AND VOLUNTEERS – The wheelchairs need to be assembled (approximately 30 minutes per chair for 550 chairs). Can you gather volunteers to assemble the chairs? | Yes No |
| 6. TRANSPORTATION – If needed, do you have land transportation (large trucks) to go from the port to your local area? | Yes No |
| 7. STORAGE – Do you have a temporary storage area for the wheelchairs until they can be put together and distributed? | Yes No |
| 8. IMPORT – Do you have the structure and necessary permissions to import a container? | Yes No |
| a. Please provide documentation of your licenses and/ or registration. | |
| b. Upload import documentation if available. | Upload Clear |
| 9. DUTIES AND CUSTOMS CLEARANCE – (Please note that It is required that all of our distribution partners have previous experience in importing containers, if you do not you will not qualify to receive a shipment from FWM) |
| a. Can you import it duty free as it is for humanitarian aid effort and the contents will be given away for free? | Yes
No
|
| b. Please give three examples in which you successfully imported and cleared a container in the past. Please list who (which organizations) you received donations from and how the clearance process went. |
| Organization #1 | |
| Clearance Process #1 | |
| Organization #2 | |
| Clearance Process #2 | |
| Organization #3 | |
| Clearance Process #3 | |
| 10. DISTRIBUTION |
| a. Please quantify number of wheelchairs that are needed for your organization or area? | |
| b. Can you please provide a time frame for distribution? | |
| c. Can you also please describe in detail how you would distribute the wheelchairs and determine who will receive them? | |
| 11. MANUALS AND TRAINING |
| a. FWM will provide a wheelchair user manual for each recipient. What language do you need the manual to be in? | |
| Can you do the translation if necessary? | Yes No |
| b. In addition to giving each recipient the user manual, FWM requires that each recipient be given brief training on how to use the wheelchair. |
| Do you have experience in physical or occupational therapy, or have access to someone in the medical field who can assist? | Yes No |
| 12. FUNDING |
| a. Are you able to obtain funding, private or government grants, or corporate sponsorships? | Yes No |
| b. Are you able to take financial responsibility for customs, duties, and inland transportation costs? | Yes No |
| | Free Wheelchair Mission will make arrangements to ship to the international shipping port of our choosing. The Distribution Partner will be responsible for any other shipping charges from that international port to any local port (if there are other shipping charges involved).
|
| 13. REFERENCES |
| Contact information from 5 organizations (preferably in the US) that your organization has worked with. Please include name, organization/company name, address, phone number and email. |
| | Reference 1 |
| | Reference 2 |
| | Reference 3 |
| | Reference 4 |
| | Reference 5 |
