Eligibility Form

Eligibility Requirements MAP International seeks to partner with those who see a world where all people have access to life-changing medicine and health supplies. MAP serves all people, regardless of religion, gender, race, nationality, or ethnic background. MAP's focus includes: In disease, Health In disaster, Help In despair, Hope Applicants must be participating in non-profit charitable work. MAP complies with U.S. export controls and screens all applicants against government-published lists prior to releasing any shipment. Applicants must secure sufficient funding to cover MAP service fees, shipping costs and any charges related to customs clearance. The applicant must provide the following materials: Fully completed eligibility forms. Medical professionals practicing medicine outside the USA will be required to provide additional proof of licensure. Proof of charitable, non-profit status (if applicable) Additional information, if needed, will be requested to complete the Eligibility screening process. Eligibility to receive donated medicines and supplies will be determined based on the completed eligibility forms. Continued eligibility will be dependent upon reports received and adherence to the stated guidelines. MAP policy does not allow for transport of medicines or medical products to any U.S.-embargoed country, or one’s subject to economic sanctions, e.g. Cuba, Syria, Iran, North Korea and Sudan, without the ordering partner providing proof of having obtained the required licensing from the appropriate departments of the U.S. government. Guidelines Limited Stock: Since MAP’s inventory is primarily dependent on donations from the U.S. pharmaceutical industry, the types and quantities of available medicines and medical supplies will vary. Product Use: In compliance with the Food, Drug and Cosmetic Act, as amended, and Internal Revenue Service regulations, all donated products must be used exclusively for the treatment of the ill, needy and infants and may NOT be sold or exchanged for property or services or re-exported. All prescription medicines must be prescribed on-site by a qualified medical professional only. Adequate records must be maintained to document the handling and distribution of all medicines. All recipients assume full responsibility that all medicines and medical supplies donated for programs outside the United States will be used only for those programs stated at the time of request. No product may be left behind in the U.S. or brought back to the U.S. at the end of the mission. Recipients must notify MAP International prior to any changes to the original plan and request. All recipients will be required to submit a detailed plan for the storage and distribution of any unused medicines with a full report of the disposition to be completed upon return. All dated medicines and products shipped by MAP must be dispensed prior to their expiration date. In the case where product must be destroyed, notification must be given to MAP. The recipient must handle that product in compliance with the original manufacturer’s recommendations and the recipient country’s regulations. Failure to notify MAP may result in loss of eligibility for future shipments. All MAP partners must immediately report any adverse event potentially related to MAP-supplied medicines, supplies and/or products by calling MAP International at (912)280-6627 and emailing or faxing the completed Adverse Event Report form to Ae@map.org or (912)265-6170. Customs: Clearing Customs is the responsibility of the consignee/recipient. Documents are carefully prepared to assist in this process (e.g. detailed packing list, gift certificate, invoice). MAP International is not responsible for customs charges, fines or taxes. Should product be confiscated by customs officials and not released for its intended use, MAP must be notified as soon as possible. Security: Donations from pharmaceutical and medical supply companies are dependent upon the product being transported and dispensed in a secure manner upon receipt. Please exercise caution when making arrangements in other countries. Shipments to locations in the U.S. for international transport should be opened only AFTER their arrival to the overseas destination. Service Fee: Service fees are established for all shipments to recover a portion of MAP’s total annual cost to procure, receive, inventory, audit, process, and ship the donated and/or purchased medicines/supplies. Reporting: All recipients of MAP-supplied medicines and medical supplies are asked to complete and return the delivery confirmation form and submit distribution and impact reports to MAP, including human-interest stories and photographs. The submitted information including photographs and stories may be used by MAP International, its donors and mission partners to promote MAP International’s mission and work around the globe. Photos will remain the property of MAP International, will be shared with MAP donors, and will not be provided to other agents or sold for profit.

Agreement for Acceptance and Distribution By accepting receipt of this statement, the undersigned agrees with MAP International’s Mission and Vision statement and all conditions of service as explained in the Eligibility and Guidelines, including, but not limited to, the following: All donated product received from MAP International will be used exclusively in charitable work outside the U.S. and in the designated country only and will not be re-exported either to the U.S. or a third country or transferred in exchange for money, other property or services. Violation of this condition may result in prosecution to the fullest extent of the law and/or civil suit. All non-delivery/non-distribution of product due to damage, customs problems or excess amount will be reported to MAP immediately. All dated medicines and products shipped by MAP must be dispensed prior to their expiration date or destroyed in accordance with the original manufacturer’s recommendations and the recipient country’s regulations. In case of a product recall, all recipients will adhere to MAP’s recall policies and procedures. All MAP partners must immediately report any adverse event potentially related to MAP-supplied medicines, supplies and/or products. Please complete and submit the Adverse Event form you received with your Eligibility documents. Please call MAP International at 1-800-225-8550 for assistance when submitting this report. All recipients of MAP-supplied medicines and medical supplies are required to complete and return the delivery confirmation form and submit distribution and impact reports to MAP, including human-interest stories and photographs. The submitted information including photographs and stories may be used by MAP International, its donors and mission partners to promote MAP International’s mission and work around the globe. Photos will remain the property of MAP International, will be shared with MAP donors and will not be provided to other agents or sold for profit. MAP International reserves the right to review continued partnership eligibility based on compliance with reporting requirements and adherence to the stated guidelines.

Donee hereby accepts responsibility for export clearance and export license determination requirements with respect to all transactions between MAP International and Donee. Donee or its duly authorized agent in the United States shall be deemed the exporter for purposes of all applicable U.S. laws. This acceptance shall remain in effect until cancelled in writing by Donee and written notification of such cancellation is received by MAP International. Without limiting the foregoing acceptance of export compliance responsibility, Donee agrees to comply with all applicable U.S. economic sanctions and export control laws and regulations, including the U.S. Export Administration Regulations and U.S. Treasury Department economic sanctions regulations. Donee covenants that it shall not -- directly or indirectly -- sell, export, reexport, transfer, provide, donate, divert, loan, lease, consign, or otherwise dispose of any items received from MAP International to or via any person, entity, or destination, or for any use prohibited by the laws or regulations of the United States or any other applicable jurisdiction without obtaining any and all prior governmental authorizations required by law. Notwithstanding any other agreement, neither Donee nor MAP International shall take or refrain from taking any action prohibited or penalized under the laws of the United States or any applicable foreign jurisdiction. Donee’s breach of this covenant shall constitute cause for immediate termination of the Agreement between the parties. Donee agrees to indemnify and hold harmless MAP International and its affiliates for Donee’s noncompliance with these controls in connection with the items. This covenant and all remedies provided in relation thereto shall survive termination or cancellation of this acceptance of responsibility. To ensure that MAP International has complete records with respect to such transactions, Donee shall, at MAP International’s request, provide MAP International with copies of any and all export documents, including export licenses or other bases for export authorization and the Shippers Export Declarations or AES records filed, with respect to any transactions in which Donee has received items from MAP International.

I acknowledge receipt of the MAP Adverse Event form. I agree to immediately report any Adverse Event that occurs in the use of surgical, medical and health supplies to MAP International by emailing AE@map.org.*

Product Use and Packaging Restrictions