Application for Funds
(Please see instructions before completing)

ABOUT YOU AND YOUR HOSPITAL

Your name:

Your full address:

Your hospital:

Your designation:

Your telephone number:

Your fax number:

Your e-mail address as it appears:

Your e-mail address in capital letters:

ABOUT YOUR REQUEST

What are you asking for?

What does it do? 

Why do you need this item?

Who would be using it?

Approximately how many patients will benefit per month?

How would you expect to carry out maintenance and repairs if required?

Have you tried getting this item from the Department of Health in Sri Lanka?  Yes/ No

If yes what was the outcome (Please describe the reason)?  

How soon do you want this item?

PURCHASE OF THE ITEM

Is this item available for purchase in Sri Lanka? Yes / No

Is there an agent?  Yes / No

Does the agent provide a maintenance and repair service?  Yes / No

Have you attached three quotations?  Yes / No 

If you have not please describe why?

If the item is not available to buy in Sri Lanka who would be responsible for clearing the item (including clearing charges) if we were to send it from abroad?

Officers from the Charity or its representatives may want to see how the item is being used. Will you or the Head of the Institution be willing to show them the item in the future if necessary if they visit your institution?  Yes / No

Your signature : ……………………………………………… Date: ……………………….

SUPPORT OF THE HEAD OF THE INSTITUTION

Please ask the Head of you Hospital / Institution to comment on your application below with regard to the suitability of the application and sign:

Comments of the Head of the Institution:

Is this item suitable and safe to use:  Yes / No

Signature of the Head of the Institution: …………………………………………………

Date: …………………………….   Official stamp:

Please post this application to:

The Hon. Secretary
Medical Aid to Sri Lanka
14 Ashusrst Road
Barnet
Herts  EN4 9LF
UK

Instructions for completing the application form for funds

This charity aims to fund items totalling up to £4000 per annum currently.  However, the charity is willing to consider more expensive items for fund raising.
The charity will only consider applications for  items within its aims and objectives.
All applications should me made using this application form.
Application form must be completed fully using block letters in black ink or should be type written.
If certain questions are not applicable this should be stated on the application form rather than leaving the space blank.
Incomplete applications will not be considered.
In certain situations a member of the  Charity’s local committee members (in Sri Lanka) will contact the applicant if further information is required. 
Wherever possible items will be bought in Sri Lanka so that repairs and maintenance could be carried out when required.
It is expected that the applicant will fully explore the compatibility of the equipment and its suitability to the hospital environment.
Please enclose THREE quotations for the item where possible with the application.

 Any inquiries should be directed to the Secretary of the Charity at the above address.