INTERNATIONAL VITAMIN AND SUPPLIES APPLICATION

Transcription

1 1650 N Indianwood Avenue, Broken Arrow, OK Phone: Fax: order@blessing.org INTERNATIONAL VITAMIN AND SUPPLIES APPLICATION *PLEASE FILL OUT COMPLETELY*A NEW APPLICATION IS REQUIRED FOR EVERY TRIP* We are able to ship vitamins and supplies on the attached order form to all states. No medical provider signature is required. *PLEASE FILL OUT ACTUAL FOREIGN COUNTRY INFO* FOREIGN COUNTRY INFORMATION Foreign Mission Name Mission Director Address Will you be working with a physician from this country? Yes No WE REQUIRE AT LEAST 20 BUSINESS/WORKING DAYS PLUS SHIPPING TIME TO PROCESS YOUR ORDER. ORDERS WILL BE SHIPPED BASED ON PRODUCT AVAILABILITY AND TRIP DEPARTURE DATE. CITY & COUNTRY MEDICINE WILL BE USED IN DEPARTURE DATE RETURN DATE LAST DATE YOU CAN ACCEPT BACKORDERS SPECIAL INSTRUCTIONS? Is this the first time this ministry has used our services? Yes No Please tell us how you found about about Blessings FIRST TIME USERS, PLEASE SEE OUR INSTRUCTIONS ONLINE. PREPAYMENT AND 501(C)3 LETTER MUST BE SUBMITTED. BILLING INFORMATION Organization Name E.I.N. (Federal Tax ID #) - Billing Contact Billing Address Zip Phone Is this a home address or a church/business address? *Please note this will be used to transmit invoices. If there is another person responsible for paying invoices for this account, please indicate below. Alternate Billing Contact Alternate Billing Contact Phone Alternate Billing Contact *IF THIS ORDER WILL BE PICKED UP, PLEASE FILL OUT SHIPPING INFO WITH PICK UP PERSON S NAME & PHONE NUMBER SHIPPING OR PICKUP INFORMATION Please ship order I will pick up order Is this a residential address? Yes No Organization Name Contact Person c/o Business Name Address Zip Phone Alt Phone PLEASE SEE PAGE 2 FOR SIGNATURE & ADDITIONAL REQUIREMENTS. INCOMPLETE APPLICATIONS MAY BE DELAYED IN PROCESSING. RECEIPT OF YOUR ORDER WILL BE CONFIRMED VIA SENT TO THE BILLING CONTACT PERSON. IF YOU DO NOT RECEIVE AN ORDER ACKNOWEDGE- MENT VIA WITHIN 3 BUSINESS DAYS, PLEASE CONTACT US AT IT MEANS WE DID NOT RECEIVE YOUR ORDER. Form VS-INT 1 of 6 International Vitamin and Supplies Application Page 1

2 INTERNATIONAL VITAMIN AND SUPPLIES APPLICATION TO BE FILLED OUT, SIGNED, AND RETURNED WITH A COPY OF YOUR MINISTRY S 501(C)3 LETTER (IF NOT ALREADY ON FILE) SIGNED COPY MUST BE FAXED BEFORE ORDER CAN BE PROCESSED REQUIREMENTS OF MEDICAL MISSIONS Signature may be by any person responsible for the order. The following is a list of operational requirements which outreaches must meet and concur with before Blessings International will commence and/or continue shipments of vitamins and supplies to them. 1. EXPORT DISCLOSURE All vitamins on the International Vitamin and Supplies order form have not been registered for use inside the USA. You hereby agree that it will not be used within the USA or any of its possessions & territories. Additionally, you agree that vitamins of this category will not be returned to the USA. Further, you agree that all vitamins on the accompanying order will not be used in or returned to the USA. 2. Vitamins and supplies obtained from Blessings International should be used only for the treatment of indigent patients. 3. Vitamins and supplies must not be used in a government operated hospital or clinic except by specific permission. 4. Vitamins and supplies will be distributed and employed in a way that glorifies God. 5. Within 30 days of return from medical mission trip, an original signed Pharmaceutical Feedback Form must be returned to Blessings International. Failure to do so will prevent our ability to serve you in the future. I have read and accept responsibilty to fulfill all of the Requirements of Medical Missions as the conditions for the management and distribution of all vitamins and/or medical supplies obtained through Blessings International. If the person signing below is not accompanying the trip, they agree that the above requirements are met by those who are going. Signature of Person Responsible Title (if any) Printed Name of Person Responsible Date Form VS-INT 2 of 6 International Vitamin and Supplies Application Page 2

3 01/27/16 Unit Legend 1M = 1,000 EA= Each IFE=FOR EXPORT ONLY OUT OF STOCK=NOT AVAILABLE FOR THIS TRIP BACKORDER WITH DATE IN BLANK=IS THE DATE BI EXPECTS IT DUE IN (STOCK) IF IT IS STAMPED NOT IN DATE RANGE= MEANS IT IS NOT IN THE DATE RANGE YOU ASKED FOR. Examples: 15M = 15,000 25M = 25,000 Blessings International 1650 North Indianwood Avenue Broken Arrow, OK USA Telephone Fax order@blessing.org Website: Surely blessing I will bless thee.. HEB 6: International Vitamins & Supplies These medicines are to be used solely for the ill, needy, or infants. Medicines are not for sale or resale. The handling charge may be changed at any time. Please note all charges are subject to change due to market price fluctuations and availability. We make every attempt to secure the absolute lowest charge. Description Quantity Unit Charge ANTIHISTAMINE, DECONGESTANTS, 4532 Cough drops cherry flavored x 720 $ Cough drops honey lemon flavor x 720 $ Cough drops Menthol flavor x 720 $25.95 VITAMINS, MINERALS 2199 Multivit: Children chewable without iron Vit-A 2500IU;Vit-D3 400IU; x 1M $17.00 Vit-B1 1.05mg; Vit-B2 1.2mg; Vit-B6 1.05mg; Vit-B12 4.5mcg; Vit-C 60mg; Vit-E 15IU;Niacin 13.5mg 2196ZMC1 Multivit: Child chew w/iron,zn: Vit-A 2500IU;Vit-D 400IU; Vit-B1 1.05mg; x 27M+ $ Vit-B2 1.2mg; Vit-B6:1.05mg; Vit-B124.5mcg; Vit-C 60mg; Vit-E 15IU; Niacin 13.5mg; Iron(as ferrous fumarate) 15mg.ZINC [BOX CT IS 27,273] 2196 Multivit: Children chew w/iron: Vit-A 2500IU;Vit-D 400IU; Vit-B1 1.05mg; x 25M $ Vit-B2 1.2mg; Vit-B6 1.05mg; Vit-B124.5mcg; Vit-C 60mg; Vit-E 15IU; Niacin 13.5mg; Iron(as ferrous fumerate) 15mg Multivit: Children chew w/iron: (Same content as ) x 1M $ Multivitamins w/fe & I: VitA w/beta carotene 5000IU; VitD 400IU; VitC x 25M $ mg; VitB1 1.5mg; VitB2 1.7mg; VitB6 2.0mg; niacinamide 20mg; Ca pantothenate 10mg; folic acid0.4mg;vit-b12 6mcg;Iron as fumarate 18mg;IODI18mg;IODINE 0.225mg RDA VITAMINS W/IRON & IODINE[BOX CT 25,200] 3250 Multivitamins w/fe &I: (Same content as ) RDA x 1M $17.00 VITAMINS/IRON/IODINE 1900B Multivitamins:without IRON & IODINE:VitA 5000IU;VitC60mg; x 25M $ VitD-3 400IU;VitB-1VitB- 21.7mg;Niacin 20mg; VitB-6 2mg;VitB-12 6mcg; VitE30IU;Foliate 400mcg;Pantothenic Acid 1mg; 1900 Multivitamins: without IRON & IODINE :VitA 5000IU;VitC60mg;VitD-3 400IU; x 1M $17.00 VitB-1VitB- 2,1.7mg;Niacin 20mg; VitB-6 2mg;VitB-12 6mcg; VitE30IU;Foliate 400mcg;Pantothenic Acid 1mg; 3199 Prenatal vitamins: (Same content as ) x 500 $ Prenatal vitamins: Vit-A 4,000IU; Vit-D 400 IU; Vit-E11 IU; Vit-C 100mg; x 16M+ $ Vit-B1 1.84mg; f olic acid 0.8mg;VitB2 1.7mg; niacinamide 18mg; Vit-B6 2.6mg; Vit-B12 4mcg;Ca 200mg; Fe 60m g (as fumerate); Zn 25mg (as o25mg (as oxide) [BOX CT IS 16,667] 3968 Infant Multivitamin drops w/iron: A-1500 IU, D-400 IU,E-5 IU, C-35mg, x 6 $25.30 B1-0.5mg, B2-0.6mg, Niacin 8mg,B6-0.4mg, Iron 10mg/1mL (50mL) 1 2/3oz dropper bottle LIQUID[LIKE POLY-VI-SOL W/IRON] OPHTHALMICS & OTICS 8100 Reading Glasses-variety pack assorted powers-from +1/+1.25/+1.5/+1.75/+2/+2.5 x 19 $ Glasses for near-sighted (-1.0 to -4.5)adjustable on side of each ear piece. x EA $13.50 DENTAL 1687 Toothbrushes,pre pasted x 20 $ Toothpaste w/flouride 1.5oz x 12 $3.20 PAGE 1

4 Description Quantity Unit Charge BOOKS 4252 A Comprehensive Guide To Missions / Karen Bean, RN. book, written by x 1 $35.00 a missionary vast experience, is designed to be a practical manual for anyone involved in foreign missions Coloring Books to help promote burn safety/central America printed in x 1 $1.50 Spanish w/crayons Coloring Books to help promote good hygiene/central America printed in x 1 $1.50 Spanish w/crayons 6009 Coloring Books to help promote good hygiene/africa- printed in Swahili x 1 $1.50 w/crayons 6011 Coloring Books to help promote good hygiene/africa- printed in English x 1 $1.50 w/crayons Coloring Books to help promote good hygiene/haiti- printed in Creole x 1 $1.50 w/crayons PERSONAL PROTECTION PRODUCTS 6200 Water purification tabs (Potable Aqua) 2 tabs = 1qt. / 1 bottle = 6 gals x 50 $ Water purifier Outback bucket system, 5-gallon pour through, gravity- x 1 $ feed unit. No water pressure required Purifies 1,500gallons at 8 gal/hr OutBack bucket purification replacement cartridge x 1 $ OutBack bucket-water sediment filter (prefilter) 30 micron replacement x 1 $21.00 BANDAGES & SURGICAL SYRINGES, TAPE, GAUZE, MISC 3195 Adhesive bandage 1" x 3" sterile non-stick [LIKE BAND-AIDS] x 100 $ Adhesive flexible fabric bandage 3/4"x3" sterile non-stick [LIKE BAND- x 100 $ Alcohol prep pads 200/box x 200 $ Butterfly wound closures (M) 3/8x1 7/8 (medium) x 100 $ Butterfly wound closures (LG)1/2x2 3/4 (large) x 100 $ Cap Nurse's blue x 100 $ Cotton tip applicators 6" non-sterile x 100 $ Elastic bandage 2" x 5 yds. x 10 $ Elastic bandage 3" x 4.5 yds. x 10 $ Elastic bandage 4" x 4.5 yds. x 10 $ Face mask ear loop x 50 $ N95 Respirater mask w/nose cushion & tan straps (SMALL) x 20 $ N95 Respirater mask w/nose cushion & tan straps (Medium) x 20 $ Gauze-sterile 2x2x8ply (2 sponges/env)sterile x 50 $ Gauze sponge 2x2x8 ply in ready to sterilize bag x 200 $ Gauze sponge 4x4x8 ply in read to sterilize bag x 200 $ Gauze sponge 4x4x8 ply sterile bag(2 sponges/env) x 50 $ Gauze sponge 4x4x8 ply sterilize bag(2 sponges/env) x 25 $ Gauze sterile 4.5" x 147" 6 ply roll krinkled x 1 $ Gloves latex powder free small x 100 $ Gloves light powder latex (XS)x-small x 100 $ Gloves light powder latex (S) small x 100 $ Gloves light powder latex (M) medium x 100 $ Gloves light powder latex (L) large x 100 $ Gloves powder free Nitrile (S)SMALL x 100 $ Gloves powder free Nitrile (M) medium x 100 $ Gloves powder free Nitrile (L) large x 100 $ Gloves powder free Nitrile (XL) X-large x 100 $ Gloves latex surgical sterile (pairs) size 6 1/2 x 50 $ Gloves latex surgical sterile (pairs) size 7 x 50 $ Gloves latex surgical sterile (pairs) size 7 1/2 x 50 $ Gloves latex surgical sterile (pairs) size 8 x 50 $ Gloves latex surgical sterile (pairs) size 8 1/2 x 50 $ Hand Sanitizer w/moisturizing kills 99% germs-4oz flip top x 1 $ M Surgical gown reinforced (sterile):contents inculde-)1gown,2 hand towels, (MED) x EA $ L Surgical gown reinforced (sterile):contents inculde- ) x EA $3.75 1gown,2 hand towels,(large) Page 2

5 Description Quantity Unit Charge 1196XLSurgical gown reinforced (sterile):contents inculde- x EA $3.75 1gown,2 hand towels,(x-large) 1781 Sterilization Pouch 7.5x13 self-sealing (if you need more deals please call office) x 200 $ SPLINT 36"-lightweight, reusable, waterproof, compact, radiolucent, versatile, x 1 $6.00 longitudinal bend to give the splint strength. works for double layer wrist splintsugar tong arm - splint ankle stirrup splint c-curve to create 3783 Tape, adhesive surgical paper 1"x10 yards hypo allergenic x 12 $ Tongue depressor blades adult 6" x 3/4" x 500 $ Tongue depressor blades junior x 500 $ Towel Drape disposable, sterile x 50 $ Unna Boot Bandage x 1 $ PICTURE DOSING LABELS ONLY/same design that's on 3x4 baggies- x 10 $ labels to unit 4257 Zip lock bags 3"x4"x2mil; with picture dosing & white block for writing x 100 $2.50 FDA approved materials 4542 Zip lock bags 3"x5"x2mil; plain double bagged will hold up 120mL liquid x 100 $3.00 EQUIPMENT & MISCELLANEOUS tsp oral medicine syringe 5mL x 10 $ tsp child medicine spoon x 10 $ oz empty plastic cough syrup bottles x 10 $ Empty-1/2oz round hinged lid plastic container-can be used to divide up x 30 $7.50 creams/ointments 9008 Empty-plastic 60cc bts w/lids and labels x 10 $ Ear Syringe 1oz x 1 $ PICTURE DOSING LABELS ONLY/same design that's on 3x4 baggies- x 10 $ labels to unit 9006 Asthma Mentor-peak flow meter adult or pediatric x 1 $ K Blood glucose monitor; include monitor,manual,battery,carring case, 10 lancets, x 1 $15.00 Lancing device,10 test strips and log book MONITOR IS A TRUE TRACK 9004 Blood glucose monitor; include monitor, manual, battery, carrying case, x 1 $2.00 [MONITOR IS A TRUE TRACK] 9002 Blood glucose test strips; for TrueTrack x 50 $ Lancets; for use with either all monitors requiring 28g x 100 $ Instant Cold Packs 4"x5" squeeze-knead-apply x 1 $0.45 PMTR Patient Medical Treatment Record- in packs of 50 x 50 $ Reading Glasses-variety pack assorted powers-from +1/+1.25/+1.5/+1.75/+2/+2.5 x 19 $ Glasses for near-sighted (-1.0 to -4.5)adjustable on side of each ear piece. x EA $ Medicine cups 1oz disposable: 100 cups / bag x 100 $ Mosquito Nets: treated w/ deltamethrin-130cmx180cmx150cm(rectangular) x 1 $ Nebulizer handheld AC adapter included x 1 $ Nebulizer handheld AC adapter Pediatric-Margo-Moo portable red barn x 1 $57.75 carrying case 3666D Nebulizer handheld AC adapter Pediatric-Digger Dog w/dog House carrying bag- x 1 $ M Medicine cup, angled mouthpiece, 7" air tubing, child mask, and instructions in Spanish 2301R Otoscope economy (requires 2 C batteries) x 1 $ A Otoscope Disposable Ear specula Adult x 100 $ C Otoscope Disposable Eat specula Child x 100 $ Ophthalmoscope/Otoscope w/eurolight (E10) requires 2 " C" batteries x 1 $ Pill Crush, crash tablets into powder x 1 $ Sharps- container red large 10qt (biohazard waste) x 1 $ Blood Pressure Monitor w/large cuff & AC adapter, comes w/4aabatteries x EA $ Sphygmomanometer adult precision aneroid nylon cuff x 1 $ Sphygmomanometer child (precision aneroid) w/ blue nylon cuff x 1 $ Sphygmomanometer infant (precision aneroid) w/ blue nylon cuff x 1 $ Sphygmomanometer XL adult precision aneroid nylon cuff x 1 $ Stethoscope fetal 29" black vinyl Y-tubing x 1 $ Stethoscope spectrum dual head x 1 $ Stethoscope spectrum nurse, black x 1 $ Tablet cutter x 1 $ Tablet/Pill, tray counter w/spa x 1 $ Thermometer INFRARED forehead scan, guidebook in english & spanish x 1 $60.00 Page 3

6 Description Quantity Unit Charge 3327 Thermometer DIGISCAN multi-function ear &forehead scan-talking x 1 $25.00 in,english & Spanish (no probe covers with this one) -(probe covers # 4332) 3707 Thermometer DIGITAL w/beeper, memory, and fever alarm, x 1 $5.65 battery included.(probe covers #3153) 4332 Thermometer probe covers DIGITAL EAR disposable TENDER TEMP x 40 $6.25 PROBE COVERS 3153 Thermometer probe covers DIGITAL oral disposable x 50 $3.40 Custom Paper work for the Country s PRO Proforma (signed, stamped and sealed) in box only x 1 $2.00 Proforma will be to the address (that you) provide for us x 1 $4.00 address: Then Proforma will be sent with order in Box 1 ELS Proforma - designed for the country of El Salvador ONLY x 1 $7.00 These will be to you also, please provide the address it should go to PAN Proforma- designed for the country of Panama ONLY x 1 $10.00 These will be to you also, please provide the address it should go to COQ Certificate of Quality and Authenticity x 1 $2.00 GC Gift Certificate x 1 $2.00 COA Certificate of Analysis issued by manufacturer for every IFE product x per item $2.00 on your order.(only available on For Export Only products that the ndc s ) IF YOU DO NOT RECEIVE AN ORDER ACKNOWLEDGEMENT IN 3 BUSNIESS DAYS PLEASE CALL OUR OFFICE. We have not received your order if you have not received an from us. Due to the increased volume of orders and our turnaround time from our suppliers you will see BK(back orders) on some of your orders. Please mark in the blank below the latest date you can receive a BK (back order) item or NO if you do not wish to have back orders shipped to you. Date: Blessings cannot guarantee that you will get your BK but with this date we will do everything we can. If a date is written in the blank on the packing list of your original order that is the day that we expect to ship it to you. PLEASE FAX ALL PAGES OF THE ORDER FORM TO INSURE WE HAVE THE COMPLETE ORDER. Page 4