Distribution Partner Application

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PARTNER APPLICATION

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To print out a form containing the questions below, click here.

NOTE: Fields marked with * are required.

How did you hear about us? *

1. ORGANIZATION

a. Organization's Name

b. Name of representative filling out application

c. Address

City      State    ZIP

d. Phone

e. Website

f. Email *

g. Countries that your organization will distribute to - Please list according to preference.

2. HISTORY OF YOUR ORGANIZATION

a. Year founded

b. Main activities

c. Description of your programs

d. 501(c)(3) - if so, please provide a copy of the front page by faxing it to our office at 949-273-8471.

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, 550 chairs). Can you gather volunteers to assemble the chairs?

6. TRANSPORTATION - If needed, do you have land transportation (large trucks) to go from the port to your local area?

7. STORAGE - Do you have a temporary storage area for the wheelchairs until they can be put together and distributed?

8. IMPORT - Do you have the structure and necessary permissions to import a a container?

9. DUTIES AND CUSTOMS CLEARANCE -

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. It is required that all of our distribution partners have previous experience in importing containers. 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. ARE YOU ABLE TO OBTAIN FUNDING, private or government grants, or corporate sponsorships?

12. Are you able to take financial responsibility for customs, duties, and inland transportation costs?

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 – Please list 3 -5 organizations that your group has worked alongside who will be available for us to contact during the qualification process. Please include name, organization/company name, address, phone number and email.

You will be contacted by a representative of FWM within 2 days.

THANK YOU VERY MUCH FOR SUBMITTING THIS INFORMATION!
To print out a form containing the questions above, click here.

If you have any questions, please email us using this form.

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