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Vision Outreach - Equipment Loan

Vision Outreach International - Equipment Loan

Following is a brief questionnaire designed to help us help you. Your participation in this effort provides the groundwork for synergy, partnership, and effective communication. Please read the follow information, check all that apply, and give us as much detail as possible. Thank you!

Today's Date
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Your Name(*)
Please let us know your name.

Your Email(*)
Please let us know your email address.

Phone or Cell(*)
Put your cell or landline contact number.

Please give us the name of the VOI representative with whom you have communicated.
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Basic Trip Information

Trip City and Country(*)
Please put the city and country of where the mission will be serving.

Trip Dates
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Total Dates Needed - (please include PRE and POST shipping dates)
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DATE NEEDED: (in your possession by:)
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"In Country" Contact Information

Organization's name (if Not VOI)
The name of any affiliated organization that will be working with this trip.

Contact person
Put the name of any in country contact or associate.

Contact Email
Please add the email of the contact.

Contact phone
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Equipment Requested

Name or type of equipment requested(*)
Please list the name of the trip organizer.

Please give a brief description of your mission and purpose.(*)
Please let us know your mission.

Expected Number of Surgeries
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Other Information
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Basic Instructions and Information

NOTE: The EQUIPMENT may be overweight and thus incur extra baggage charges for international travel. Please weigh the EQUIPMENT and repack in securely padded luggage.

1. Complete and Agree with this form and submit.

2. Send a $500.00 deposit to:

Vision Outreach International
2848 Niles Road
St. Joseph, MI 49085
or
Donate $500.00 by going to:
http://www.visionoutreach.org/index.php/donate
Be sure to use the same name on this form or inform us of the change at info@visionoutreach.org


3. The following items will be deducted from the $500 deposit. (a. shipping cost, b. equipment insurance, c. any credit card processing fees)

4. Once the form and deposit have been received and approved, your dates will be placed on the VOI calendar.

5. Equipment will be shipped to you according to your date preference.

6. Once the equipment is returned & reviewed at Vision Outreach the remainder of the deposit will be reimbursed to you.

7. Should there be any discrepancies or concerns, VOI will notify you via phone or email.

8. PLEASE CONSIDER MAKING A DONATION TO VOI FOR ITS ON-GOING WORK TO HELP THE BLIND POOR WORLD-WIDE.

By checking "YES, I agree" below, You hereby attest that the information provided above is true and you are the individual whose name appears on the line (YOUR NAME) of this form.

Furthermore, by clicking "YES, I agree" below, you agree that you have read all the information in this form and agree to abide by the Vision Outreach International, Inc. (VOI) instructions listed above, release VOI of all liability pertaining to this equipment, and your involvement in the above mentioned mission trip. You have agreed to participate in this trip voluntarily and understand the risks involved in this type of work and international travel.

If you agree with these statements, please click, "Yes, I agree"

"Yes I AGREE"(*)
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PLEASE DO NOT REFRESH, GO BACK, OR "X" OUT OF THIS PAGE. IT MAY TAKE SEVERAL MINUTES FOR THE FORM TO SUBMIT

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