Application for United States Free Clinics Step 1 of 333%Application for United States Free Clinics Please note: While Advocates for World Health is happy to help with some of your clinic’s supply needs, we do not have a large enough inventory to provide everything you will need. We are to be used as an occasional donator, not as a regular supplier. Contact InformationName of Clinic*Contact Person*Title*Phone*Email* Website Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Type of Organization*501 (c) (3) Non- Profit Organization ( please furnish letter of determination )Faith-based Organization General InformationHas the facility received assistance from Advocates for World Health in the past?*YesNoI don't knowIf yes, when?Facility InformationWho owns/ operates the clinic?*What is the legal status of the clinic?*Private, For-ProfitPrivate, Not-For-ProfitReligiousPublic/ GovernmentDescribe funding of the clinic (i. e. fee for service, donor, government, etc.)Please indicate the annual budgeted allowance and actual annual expenditure for reoccurring medical supplies for the most recent complete financial year. ( Please remember that “Supplies” refers to non-pharmaceutical and non-equipment materials) Financial Year (e.g. July 07 to June 08)*Budgeted Amount ( in dollars )*Actual Expenditure ( in dollars )*Please indicate the type of facility ( if the facility is outpatient only, please indicate a “0” in number of beds ).Type of Facility*Urban HospitalUrban ClinicRural HospitalRural ClinicNumber of Beds ( if applicable )*What is the total number of staff at the facility?*Total number of patients the facility treats per month:MenWomenUntitled0-5 Years Old:TotalNumber InpatientsNumber Outpatient6-15 Years Old:TotalNumber InpatientsNumber Outpatient16-49 Years Old:TotalNumber InpatientsNumber OutpatientOver 50 Years Old:TotalNumber InpatientsNumber OutpatientTypes of Medical Service Provided at the Facility ( check all that apply )* Primary Health Care Dental Gynecology Nutritional Service Surgery Ear, Nose and Throat General Medicine Mental Health Obstetrics Pediatrics Immunizations Laboratory Orthopedics Traditional Medicine X-ray/ Imaging services Family Planning Health Education Emergency Care Eye Care Other ( Please describe below) UntitledWhat are the major health problems treated at your facility?Provide a general list of supplies and specific list of biomedical equipment needed. (Advocates for World Health does not receive, store or ship pharmaceuticals) Supplies* Biomedical Equipment* Community InformationWhat is the estimated population size of the geographic area served by the facility?*Untitled*Untitled*In considering medical supply, which situation best describes your facility/ organization?*Supplies are not used for patient services at the facility.The facility often lacks general supplies for patient servicesThe Facility often lacks specialized supplies for patient services.The facility often has adequate supplies for all patient services.The facility often has surplus of supplies for patient services.