Appendix I
FORMAT FOR SENDING OFFERS OF DONATION UNDER THE
EQUIPMENT DONATION PROGRAMME TO INDIA
(if the space is not sufficient, please attach extra sheets)
1.
a) Name of the Donor ________________________________
b) Address : ________________________________
________________________________
c) Telephone-Work: ________________________________
Residence : ________________________________
2.
a) Name of the Equipment ________________________________
b) Manufacturer ________________________________
c) Model No. ________________________________
d) Cost of the equipment in U.S. Dollars ______________________
e) Technical Details ________________________________
f) Year of Manufacture ________________________________
g) Present Condition ________________________________
(Certificate to be attached)
h) Name of the Agent in India ________________________________
i) Spares/Accessories Sent : ________________________________
Number. ________________________________
j) Catalogue/literature included ________________________________
3.
a) Name of the Hospital/Medical College
________________________________ to which the Equipment is
to be sent :
b) Address : ________________________________
________________________________
4.
a) Number of Packages ________________________________
b) Dimensions of each package :
_______________________________
Package No. 1_______________________
Package No. 2_______________________
Package No. 3_______________________
Package No. 4________________________
c) Weight of each package :
Package No. 1_______________________
Package No. 2________________________
Package No. 3_______________________
Package No. 4________________________
d) list of items in each package :
Package No. 1_______________________
Package No. 2________________________
Package No. 3_______________________
Package No. 4________________________
e) Name of the representative who will hand over
the consignment in U.S.A.
___________________________________
______________________ ___________________________
Date Signature
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