Cancel

OK

You have successfully logged out.

Product Donation Request Form

Donating our products to support underserved patient care and humanitarian needs

We are proud to play a leadership role in advancing health equity, and believe all patients should have access to our products when medically necessary.

Our focus

We focus our Product Donations on voluntary medical care delivered to underserved patient populations and for humanitarian need where no reimbursement from government or commercial entities is requested by the organization or treating healthcare provider.

Important Note: B. Braun will not ship donated product across country borders and may not be named as the exporter of record for shipments to international destinations.

If your program falls within our areas of focus as described above, we invite you to request a Product Donation from B. Braun. For any questions, or if you encounter any problems, please send us an email at GrantRequests@bbraunusa.com.

Product Donation Request Form

Requesting organization name *

Requesting organization address line 1 *

Requesting organization address line 2

Requesting organization city *

Requesting organization state *

Requesting organization zip code *

Requesting organization country

Requesting organization tax ID number *

Requesting organization tax status *

Select One

Select One
501 (c) (3) Corporation
501 (c) (6) Corporation
Other

Requesting organization type *

Select One

Select One
Healthcare Organization
Non-Healthcare Organization

Requesting organization contact name *

Requesting organization contact job title *

Requesting organization contact email *

Requesting organization contact phone *

Event or mission name *

Event or mission start date *

Event or misson state *

AL

Event or mission country *

Event or mission description *

Estimated number of patients treated *

Identify the requested product name (or SKU), description and quantity of the product requested. *

Requested delivery date of product(s) *

Describe how the donated product will be used. *

Full name of clinician under whose direction donated product will be used *

License number of clinician *

Credentials of clinician *

Email address of clinician *

Phone number of clinician *

Country of residence of clinician *

Name of medical facility where product will be used *

Address of medical facility where product will be used *

Product shipping information (may not be to a personal address) if different from organization information provided above:

Ship to name

Ship to address

Ship to contact name

Ship to contact email

Ship to contact phone

Ship to contact’s relationship to organization

Will you agree to return any unused product to B. Braun? *

Will your organization be fully responsible for any shipment of donated product across country borders and be named as the exporter of record for any such shipments? *

The following supporting documentation must be attached and submitted with the Product Donation Form (Please hover over the field to see your document):

1. Non-profit designation letter *

cloud_upload Drag and Drop files, or click to browse

2. IRS form W9 *

cloud_upload Drag and Drop files, or click to browse

3. Statement of charitable mission *

cloud_upload Drag and Drop files, or click to browse

4. If requesting products a complete list of the products requested using product name (or SKU) and quantity of each. This information can be found on B. Braun’s website. *

cloud_upload Drag and Drop files, or click to browse

By submitting this request, I acknowledge the B. Braun will require a signed agreement in the event my request is approved and before providing the approved support.