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Ge Healthcare Primary Care Service Contract

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					                                            USA Product Donation Request Form
                                                                   GE Healthcare Clinical Systems
                                         web




GE has a longstanding commitment to Corporate Citizenship throughout the world. As a part of this,
GE Healthcare recognizes its obligation as a responsible and caring member of the communities in
which it serves and looks to ways that it can charitably contribute and support those in need.

FORM INSTRUCTIONS:

This is a product request form only. GE Healthcare’s receipt of this completed form does not imply any
commitment to approve the request or provide any requested equipment.

   1. Complete this application form.

   2. Include a brief cover note (no more than 1 page) on your organization’s letterhead.

   3. Submit both documents via email to: ProductDonationRequest@ge.com
       If you don’t have emailing capabilities for letterhead and signature page, please fax complete form to 1-414-755-0929 (eFax).


Applicable Law:
In order to be eligible for charitable donations from GE Healthcare, organizations must comply with applicable
law and regulations.

Non-USA Organizations:
If your organization is not based in the United States, it must have equivalent status as a tax-exempt
organization or be a government-run public school or university. If your organization is not recognized as a US
Internal Revenue Service 501(c)(3) organization, please request and complete a Non-USA equivalency
questionnaire.

USA Organizations Tax-Exempt Eligibility Requirements 501(c)(3):
Organizations considered for GE Healthcare charitable donations must be tax-exempt as defined in Section
501(c)(3) of the US Internal Revenue Service Code, or an equivalent organization based outside the USA.

Please insert your 501(c)(3) number:
Date your organization’s tax exempt status was last verified:

Attach a copy of your 501(c)(3) letter showing that you are a public charity.

NOTE: If you are an individual requesting an equipment donation on behalf of a local
healthcare facility, you must attain sponsorship from a 501(c)(3) organization.
(For example, as a volunteer surgeon, you have just completed a stay in Bolivia at a rural hospital and would
like to obtain medical equipment for their utilization. Your volunteer organization or another applicable
501(c)(3) non-for-profit must complete this form.)

Date Request Submitted:


                                                                    1
Your Organization’s Information

Requesting Organization

Legal Name:
Website:

Address:
City:                                      State:                Postal Code:

Tax ID Number:


Primary Contact Information

Full Name:
Title:

Address:
City:                                      State:                Postal Code:

Office Phone:
Cell Phone:
Email Address:


Hospital Affiliation (if any)

Legal Name:
Website:

Address:
City:                                      State:                Postal Code:


GE Referral Contact Information (if any)

GE Employee Full Name:

GE Employee Position (if known):

GE Company (For example: GE Healthcare, GE Energy, GE Finance):

What is your relationship with this person? Please explain. (For example: Member of your Board,
your Sales Representative, partner organization referred this GE Employee name, personal friend, etc.)




                                                      2
Your Organization’s Overview

Please summarize the mission and goals of your organization.




What inspired you to ask GE Healthcare for equipment donations? Please explain. (For example:
product reputation, referred by colleague or customer of GE, advertising, personal experience, etc.)




GE Healthcare has clearly defined product donation focus areas. Which area would this
donation most impact?

   1) Disaster Relief and/or Recovery
   2) Healthcare Service to an Under/Uninsured Majority Patient Base


   Please explain your choice above.




Is your organization Local, National, or International?

Are you affiliated with another organization?

   If so, please identify.


What geographic area do you serve?


Has your organization received product donations from GE Healthcare in the past?

   If so, please indicate the following (if known):

   Product(s):

   Approximate Receipt Date:

   GE Contact (who coordinated the transaction):




                                                       3
GE Healthcare Product Request

What product group are you requesting? (Anesthesia, Infant Care, Patient Monitoring or Ultrasound)



What is the product name (and part# if known)? (For example: Aespire, Giraffe, Dash4k, LogicPro)



How many units are you requesting?


Anticipated Need Date:


What specific need will this equipment satisfy? (For example: replacement of current failed unit or
building a new organization that needs equipment or additional units to support growing patient population or
desire for newer technology or a need for different functionality)

   Please explain.



Where (which community) will the equipment be used? Please provide geographic detail.


Where (within the healthcare facility) will the equipment be used?


How will the equipment be used?


Will the donated equipment be used on live bodies?


How will this donation help you achieve your goals?




                                                       4
GE Healthcare Compliance
Do you agree to sign a Property Transfer Agreement (to be provided), taking title of the
equipment upon delivery?

Do you agree to return a completed IRS Form 8283 (to be provided) acknowledging a donation
receipt from GE Healthcare?

Do you agree to act in compliance with the applicable GE Healthcare product guidelines?


Do you agree to install and use the equipment properly and as instructed in the installation
and operating manuals?

Do you agree not to sell, trade, donate or loan the equipment to any other organization other
than that listed herein as the requesting organization?

Do you agree that when “end of life” (as determined by GE Healthcare or any other
responsible organization) occurs for this product in your organizations utilization, that you
will dispose/destroy it properly? (Non-compliance will automatically eliminate your eligibility for future
donations from GE Healthcare)

Do you agree that the equipment is donated “AS IS” in all respects? (GE Healthcare will not
provide warranty or support services unless contractually negotiated through the Service Team or performed
on a time-and-materials basis at your request)

Do you agree that any installation service charges are at the expense of your organization and
not GE Healthcare?

Do you plan to publicize the donation? (Any organization or affiliate that receives donated equipment
from us must obtain authorization to publicize the identity of the donor and must use the full “GE Healthcare”
name rather than “GE”)

Do you agree to GE Healthcare’s Limitation of Liability? GE Healthcare shall not be responsible or
liable with respect to the donated equipment (property), and damage or harm caused by the property, and
subject matter of this agreement or the terms or conditions related thereto under any theory of contract,
negligence, strict liability, or any other theory of liability (a) for loss or inaccuracy of data or cost of procurement
of substitute goods, services or technology, or (b) for any direct, indirect, incidental or consequential damages,
including but not limited to loss of revenue and loss of profits, even if we have been advised of the possibility of
such damages, or (c) for any claim by any other party relating to the property, or any damage or harm caused
by the property.

Do you agree that any GE equipment donated to your organization will only be used for
medical purposes, and will not be used for any recreational or other purpose?

Do you agree not to utilize this equipment in embargoed countries as defined by the US State
Department?

Link to US Bureau Industry and Security (check current embargoed countries):
http://www.bis.doc.gov/PoliciesAndRegulations/05ForPolControls/Chap5_Embargo.htm

                                                           5
Authorized Signature
The undersigned, an authorized officer of the organization, does hereby certify that the
information set forth in this donation request form is true and correct, and that the Federal tax
exemption determination letter attached has not been revoked and the present operation of
the organization and its current sources of support are not inconsistent with the
organization’s continuing tax exempt classification as set forth in such determination letter.


Signature:                                                Date:


Name:

Title:



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