Note:
Please read carefully and proceed with application if you agree with the process and Conditions laid out below:
All inforamtion requested in this form must be completed and properly explained with supporting documents , as appropriate.
Hidaya will review all applications and response will be sent only to the qualified applicants with request for additional information and documentation as deemed appropriate by Hidaya.
If Approved,the selected party will be responsible for transporation/Shipment of the equipment from Hidaya Ware House in Shikarpur, Sindh, to thier facilities with in 10 days or as agreed upon. Otherwise it will be awarded to the next qualified applicant.
If selected for awarding the equipment, you hereby agree to allow Hidaya personnel to visit your facilities at any time, without prior notice to ensure that the equipment awarded is in good use.
The equipment tags willbe marked as "Property of Hidaya Trust". These tags must never be removed till the equipment is unusable and Hidaya authorizes in writing to remove the equipment from hospital.Taking the tags off without permission will be considered breach of contract and Hidaya may take action. Also it will disquilify you from all future dealings with Hidaya.
Hidaya reserves the right to disqualify an applicant from receving current and/or future supplies for falsifying information.
Application Form
For requesting used hospital beds ,wheels,chairs,walkers,crutches and more
* Required Fields
Essential Information
*
Name of Hospital
*
Address
*
Main Tel #
*
E-mail Address
*
Contact person's name
*
Contact person's Title
*
Contact person's Tel #
*
How long has this Hospital /University /Institution been in operation.
Select
1 year
2 years
3 years
4 years
4 years plus
*
Type of Hospital /University /Institution.
Chairtable
Private
Govt.
*
If "Private" was checked above ;Please answer the following questions:
1)If "Private income generating .
2007 Annual gross income.
2007 Annual gross profit.
What percentage is donated /used for charitable causes.
2)If "Private non profit" .
2007 Annual gross receipts.
2007 Annual overhead as percentage(%) of receipts.
*
Is this an out-patient facility ?
Yes
No
If you answered "yes" .
How many full times employees
How many physicians available
How many patients are treatred during a given month ?
*
Is this a hospital where patients are kept for overnight or till they get better ?
Yes
No
If you answered "yes" .
How many full times employees
How many physicians available
How many patients are treatred during a given month ?
Are there any surgical procedure done at the hospital ? please describe
Please Explain your needs.
Beds
Wheel chairs
Crutches
Walkers
Medical Books
Other(explain)
For Each items checked above ,please:
*
Provide Information on the number of each of items checked above at you facility at present:
*
Justification for the need for additional supplies being requested:
*
Is hospital registered with the Govt: ?
Yes
No
*
Does Hospital completes its yearly audit by third party auditor : ?
Yes
No
*
If selected ,will your hospital /university /institution be willing to show its last two years tax and audit documents to Hidaya: ?
Yes
No
*
How would your organization ensure that the donated items are put to good use and kept in secure, maintained condition?
*
Would you allow Hidaya officials to visit your facilities during the qualification stage before you are selected to receive the equipment?
Yes
No
Any information that you feel will help you qualify for the award of the equipment:
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