HMK Application Form - Health Partners International Canada

Apply for a Humanitarian Medical Kit!

"*" indicates required fields

Application Timeline

To obtain a Humanitarian Medical Kit for primary care, fill out the application form at least 6 weeks prior to the date of departure.

If you need more time or information to complete your form, you can scroll down to the bottom and save your application and return to it.

Number of HMK(s) Requested

Please request the number of kits you would like. Please note an HMK may consist of one or two boxes with up to 600 medical treatments. Each carrier can take up to 2 kits (4 boxes). If you are requesting more than 2 kits, you will be asked to provide additional information regarding each of your carriers later on in the application.

HMK Primary Care

Special Product Request

Yes, I would like to make a Special Product Request.

No, I do not want to make a Special Product Request.

Special Product Request List

Please fill out the following table according to the example below to let us know what special products you are requesting. Use the Blue plus sign on the right side of the first row to add additional rows.

Product Name

Strength

Form

Quantity

Unit of Measure

I would like to be offered short-dated products between 4-7 months before expiry, for a contribution of $50 per box*

Yes

Contact Information

Title

Name*

Address*

Street Address Address Line 2 City Province Postal Code

Home Phone

Business Phone

Cell Phone*

Email*

Are you a healthcare practitioner (doctor, nurse, or pharmacist)?*

Yes

Enter your Licence Number:*

Are you associated with a Canadian organization?*

Yes

Please provide more information about the organization.*

Carrier Information

This is the person carrying the medicines to their final destination.

Same as Applicant*

Yes

Title

Name*

Address*

Street Address Address Line 2 City Province Postal Code

Home Phone

Business Phone

Cell Phone*

Email*

Are you associated with a Canadian organization?*

Yes

Please provide more information about the organization.*

Are you a healthcare practitioner (doctor, nurse, or pharmacist)?*

Yes

Are there additional carriers? Please fill out their information below.

Full Name

Phone Number

Email Address

Shipping Address

Shipping Address Option*

Same as Applicant

Same as Carrier

Pick up from Oakville Distribution Centre

Other

Address*

Street Address Address Line 2 City Province Postal Code

Name*

Home Phone

Business Phone

Cell Phone*

Email*

Travel Information

Expected Departure Date*

MM slash DD slash YYYY

Date of Arrival in Project Area*

MM slash DD slash YYYY

Are you travelling through another country to reach your destination?*

Yes

Which country will you transit through?*

What is the length of transit?*

Please be advised that the kits should only enter the final destination country and should not leave the airport during any transits you may have.

Expected Date of Return*

MM slash DD slash YYYY

Destination*

City Country

If you are travelling with a group, please provide a general description of its members*

(i.e. affiliations, types of healthcare professionals, etc.)

What is the total number of physicians travelling in your group?*

What is the total number of other healthcare professionals travelling in your group?*

Please provide the names of all the healthcare practitioners travelling in your group.*

Customs Information

Are you aware of customs procedures in the destination country?*

Yes

If you are unaware of the customs procedures in the destination country, please confirm the details and return to complete your application at a later time.

Minimum expiry dating requirements in the destination country, in months*

HPIC includes Packing Lists as well as a Certificate of Donation stating that all medicines are a free gift from Canada to your destination country. Do you require any other documents from HPIC for customs? If so, when?

Are you travelling through another country to reach your destination?*

Yes

Customs Procedures*

I agree to take responsibility to fully investigate customs procedures and adhere to policies of the destination country to assure safe passage. And, I am aware that HPIC is not responsible for customs clearance, foreign customs charges or taxes.

Organisation / NGO Affiliation

Are you travelling in association with a Canadian organisation/NGO?*

Yes

Name of organisation/NGO

Name & title of contact person

Address

City Province

Postal Code

Phone

Website

Is the organization/NGO a charity?

Yes

If registered, what is the CRA Number ?

Project Information

HPIC is diligent in following where our medicines/supplies are distributed and how these medicines are being used. We require details about your upcoming project to verify your trip, enable us to serve you better and share your work with our partnering pharmaceutical donors. We require a project report and photos upon completion of your mission. Short videos focused on the health aspect of your project are also appreciated.

Is the purpose of your trip to address a current emergency situation?*

Yes

Describe the objective of your project and how the medicines will be used.*

(If a project profile is available, please include.)

Who are the intended beneficiaries of the medical aid, and how will they be selected?*

Please provide demographic details (i.e. age, gender, socioeconomic background etc.)

If you will be working with another organization in the destination country to deliver and dispense these medicines*

Please share the name of the organization and their contact details.

Name of hospital/clinic in destination country*

Mobile Clinic*

Yes

Will a qualified healthcare professional be overseeing the distribution of medicine?*

Yes

Please provide their name*

Communications

Will this project be documented by blog/video/photographs?

Yes

If yes, where can HPIC find this content?

If available, please include social media accounts and blogs.

Endorsement of Carrier

(by physician, pharmacist or nurse practitioner)

The medications provided by HPIC include products requiring a prescription, therefore all carriers must be endorsed by a physician, pharmacist or nurse practitioner currently licensed in Canada, except in the case of over the counter short-dated products.

Endorser's Name*

Specialty*

Address*

City Province Postal Code

License Number*

Business Phone*

Cell Phone

Email*

Terms & Conditions*

By checking this box I vouch for the carrier and confirm that he/she will ensure the safe delivery of the requested medications in accordance with the terms and conditions outlined in this application.

About the Contribution Request

To recover a portion of the administrative and handling costs of your Humanitarian Medical Kit(s), HPIC requests a minimum contribution based on the number of kits or number of line items if you are taking a Special Product Request kit. HPIC raises funds throughout the year to co-fund your kit(s). Once your kits leave our distribution centre, you will be sent a contribution request with details on how to make your payment. Please note contributions are non-refundable. Individual contributors will receive an income tax receipt.

If you have questions about the contribution procedure, please contact HPIC at 1-800-627-1787, ext. 101 or at info@hpicanada.ca.

If you need help raising the funds for your kit, ask HPIC about a simple to use fundraising platform.

Contributor Name*

Please provide the name of the contributor (individual or organization)

Terms and Conditions

Medicines and medical supplies must be used outside Canada and only in developing countries for humanitarian purposes;
Donated medicines and medical supplies cannot be used in or marketed in or returned to Canada, or sold or exchanged for property or services;
Donated medicines and medical supplies must respond to the specific health needs of the country of final destination and be dispensed as agreed upon with HPIC to an identified group of beneficiaries and within a specified project;
Only licensed healthcare practitioners may dispense the medicines. Recipient hospitals and/or clinics and physicians must be aware of any imminent donation. In case of recall, recipients must adhere to HPIC's recall policies and procedures;
Medicine and medical supplies must be dispensed by trained healthcare practitioners who are able to read Canadian (English / French) packaging and instructions;
Donated medicines and medical supplies will be distributed free of charge and without discrimination as to race, religion, age, or gender;
HPIC must be promptly advised of any change of destination and/or distribution plan. Any change in the date of departure should be promptly communicated with HPIC for further instruction;
HPIC will be notified immediately of any loss, diversion or misuse of the donated medicines;
HPIC will be notified immediately of any adverse reaction from use of medicine(s);
The destination country’s procedure to clear the donated medicines through customs will be respected. HPIC is not responsible for foreign customs charges or taxes;
Medicines and medical supplies will not be used to support terrorist activities or organizations linked to terrorism;
In accordance with World Health Organization Guidelines for Donations, all donated medicines must be distributed and used before their expiry date, and any expired medicines must be destroyed in an environmentally safe manner;
All medicines and medical supplies must be used in adherence to HPIC’s Gender Equity Policy and HPIC’s Environmental Policy (please inquire with HPIC for copies of these policies);
The Code of Conduct for the International Red Cross and Red Crescent Movement and NGOs in Disaster Relief and The Inter-Agency Standing Committee Plan of Action on Protection Against Sexual Exploitation must be adhered to in the delivery of humanitarian aid in emergency situations.
Approval by HPIC for your humanitarian project implies that you and HPIC are partners in this endeavour. HPIC’s role is to solicit, source and prepare the medicines for shipping. Your role will be to ensure the administration and distribution of the donated medicines, and to report how they were used for humanitarian purposes outside of Canada.
HPIC requests a donation to continue its missions of providing medicines to our partners involved in humanitarian projects. HPIC receives Canadian sourced donated medicines and medical supplies with the intent of increasing access to medicine within the developing world. The tax-deductible donations we receive are used to support HPIC’s mandate.

APPLICANT*

I agree to all of the following:

The terms and conditions outlined in this application,

The HMK comes sealed and must not be opened in Canada; they may only be opened upon
arrival at the destination of distribution.

The payment of the contribution

The CONFIRMATION OF SAFE ARRIVAL form included with shipping documents will be completed immediately upon arrival of medicines at the final destination and returned to HPIC, and

The PROJECT REPORT form included with the shipping documents must be completed and returned, along with photos, within one (1) month after the arrival of the shipment in the country of destination.

By checking this box I confirm all the information in this application is accurate and true.

Applicant Signature*

Full name

Date*

MM slash DD slash YYYY

CARRIER*

I agree to all of the following:

The terms and conditions outlined in this application,

The payment of the contribution

The CONFIRMATION OF SAFE ARRIVAL form included with shipping documents will be completed immediately upon arrival of medicines at the final destination and returned to HPIC, and

First-time applicants acknowledge that flight information may be requested upon receipt of the application.

First-time applicants agree to provide a copy of their import permit.

The PROJECT REPORT form included with the shipping documents must be completed and returned, along with photos, within one (1) month after the arrival of the shipment in the country of destination.

By checking this box I confirm all the information in this application is accurate and true.

Carrier Signature*

Full name

Date*

MM slash DD slash YYYY

Apply for a Humanitarian Medical Kit!

"*" indicates required fields

Application Timeline

To obtain a Humanitarian Medical Kit for primary care, fill out the application form at least 6 weeks prior to the date of departure.

If you need more time or information to complete your form, you can scroll down to the bottom and save your application and return to it.

Number of HMK(s) Requested

HMK Primary Care

Special Product Request

Yes, I would like to make a Special Product Request.

No, I do not want to make a Special Product Request.

Special Product Request List

Product Name

Strength

Form

Quantity

Unit of Measure

I would like to be offered short-dated products between 4-7 months before expiry, for a contribution of $50 per box*

Yes

Contact Information

Title

Name*

Address*

Street Address Address Line 2 City Province Postal Code

Home Phone

Business Phone

Cell Phone*

Email*

Are you a healthcare practitioner (doctor, nurse, or pharmacist)?*

Yes

Enter your Licence Number:*

Are you associated with a Canadian organization?*

Yes

Please provide more information about the organization.*

Carrier Information

This is the person carrying the medicines to their final destination.

Same as Applicant*

Yes

Title

Name*

Address*

Street Address Address Line 2 City Province Postal Code

Home Phone

Business Phone

Cell Phone*

Email*

Are you associated with a Canadian organization?*

Yes

Please provide more information about the organization.*

Are you a healthcare practitioner (doctor, nurse, or pharmacist)?*

Yes

Are there additional carriers? Please fill out their information below.

Full Name

Phone Number

Email Address

Shipping Address

Shipping Address Option*

Same as Applicant

Same as Carrier

Pick up from Oakville Distribution Centre

Other

Address*

Street Address Address Line 2 City Province Postal Code

Name*

Home Phone

Business Phone

Cell Phone*

Email*

Travel Information

Expected Departure Date*

MM slash DD slash YYYY

Date of Arrival in Project Area*

MM slash DD slash YYYY

Are you travelling through another country to reach your destination?*

Yes

Which country will you transit through?*

What is the length of transit?*

Please be advised that the kits should only enter the final destination country and should not leave the airport during any transits you may have.

Expected Date of Return*

MM slash DD slash YYYY

Destination*

City Country

If you are travelling with a group, please provide a general description of its members*

(i.e. affiliations, types of healthcare professionals, etc.)

What is the total number of physicians travelling in your group?*

What is the total number of other healthcare professionals travelling in your group?*

Please provide the names of all the healthcare practitioners travelling in your group.*

Customs Information

Are you aware of customs procedures in the destination country?*

Yes

If you are unaware of the customs procedures in the destination country, please confirm the details and return to complete your application at a later time.

Minimum expiry dating requirements in the destination country, in months*

Are you travelling through another country to reach your destination?*

Yes

Customs Procedures*

Organisation / NGO Affiliation

Are you travelling in association with a Canadian organisation/NGO?*

Yes

Name of organisation/NGO

Name & title of contact person

Address

City Province

Postal Code

Phone

Website

Is the organization/NGO a charity?

Yes

If registered, what is the CRA Number ?

Project Information

Is the purpose of your trip to address a current emergency situation?*

Yes

Describe the objective of your project and how the medicines will be used.*

(If a project profile is available, please include.)

Who are the intended beneficiaries of the medical aid, and how will they be selected?*

Please provide demographic details (i.e. age, gender, socioeconomic background etc.)

If you will be working with another organization in the destination country to deliver and dispense these medicines*

Please share the name of the organization and their contact details.

Name of hospital/clinic in destination country*

Mobile Clinic*

Yes

Will a qualified healthcare professional be overseeing the distribution of medicine?*

Yes

Please provide their name*

Communications

Will this project be documented by blog/video/photographs?

Yes

If yes, where can HPIC find this content?

If available, please include social media accounts and blogs.

Endorsement of Carrier

(by physician, pharmacist or nurse practitioner)

Endorser's Name*

Specialty*

Address*

City Province Postal Code

License Number*

Business Phone*

Cell Phone

Email*

Terms & Conditions*

About the Contribution Request

If you have questions about the contribution procedure, please contact HPIC at 1-800-627-1787, ext. 101 or at info@hpicanada.ca.

If you need help raising the funds for your kit, ask HPIC about a simple to use fundraising platform.

Contributor Name*

Please provide the name of the contributor (individual or organization)

Terms and Conditions

Medicines and medical supplies must be used outside Canada and only in developing countries for humanitarian purposes;
Donated medicines and medical supplies cannot be used in or marketed in or returned to Canada, or sold or exchanged for property or services;
Donated medicines and medical supplies must respond to the specific health needs of the country of final destination and be dispensed as agreed upon with HPIC to an identified group of beneficiaries and within a specified project;
Only licensed healthcare practitioners may dispense the medicines. Recipient hospitals and/or clinics and physicians must be aware of any imminent donation. In case of recall, recipients must adhere to HPIC’s recall policies and procedures;
Medicine and medical supplies must be dispensed by trained healthcare practitioners who are able to read Canadian (English / French) packaging and instructions;
Donated medicines and medical supplies will be distributed free of charge and without discrimination as to race, religion, age, or gender;
HPIC must be promptly advised of any change of destination and/or distribution plan. Any change in the date of departure should be promptly communicated with HPIC for further instruction;
HPIC will be notified immediately of any loss, diversion or misuse of the donated medicines;
HPIC will be notified immediately of any adverse reaction from use of medicine(s);
The destination country’s procedure to clear the donated medicines through customs will be respected. HPIC is not responsible for foreign customs charges or taxes;
Medicines and medical supplies will not be used to support terrorist activities or organizations linked to terrorism;
In accordance with World Health Organization Guidelines for Donations, all donated medicines must be distributed and used before their expiry date, and any expired medicines must be destroyed in an environmentally safe manner;
All medicines and medical supplies must be used in adherence to HPIC’s Gender Equity Policy and HPIC’s Environmental Policy (please inquire with HPIC for copies of these policies);
The Code of Conduct for the International Red Cross and Red Crescent Movement and NGOs in Disaster Relief and The Inter-Agency Standing Committee Plan of Action on Protection Against Sexual Exploitation must be adhered to in the delivery of humanitarian aid in emergency situations.
Approval by HPIC for your humanitarian project implies that you and HPIC are partners in this endeavour. HPIC’s role is to solicit, source and prepare the medicines for shipping. Your role will be to ensure the administration and distribution of the donated medicines, and to report how they were used for humanitarian purposes outside of Canada.
HPIC requests a donation to continue its missions of providing medicines to our partners involved in humanitarian projects. HPIC receives Canadian sourced donated medicines and medical supplies with the intent of increasing access to medicine within the developing world. The tax-deductible donations we receive are used to support HPIC’s mandate.

APPLICANT*

I agree to all of the following:

Applicant Signature*

Full name

Date*

MM slash DD slash YYYY

CARRIER*

I agree to all of the following:

Carrier Signature*

Full name

Date*

MM slash DD slash YYYY

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Apply for a Humanitarian Medical Kit!

Application Timeline

Number of HMK(s) Requested

Contact Information

Carrier Information

Shipping Address

Travel Information

Customs Information

Organisation / NGO Affiliation

Project Information

Communications

Endorsement of Carrier

About the Contribution Request

Terms and Conditions

Apply for a Humanitarian Medical Kit!

Application Timeline

Number of HMK(s) Requested

Contact Information

Carrier Information

Shipping Address

Travel Information

Customs Information

Organisation / NGO Affiliation

Project Information

Communications

Endorsement of Carrier

About the Contribution Request

Terms and Conditions

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