Product Donation Form

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B. Braun considers product donation requests to support humanitarian medical treatment under the direction of charitable non-profit organizations. Product donations are subject to available inventory at the time of shipment. If approved, B. Braun will only ship donated products to the address of the organization that submitted the product donation request to B. Braun.

Recipient organizations and B. Braun acknowledge and agree that any donation shall not obligate the organization to purchase, use or recommend the use of any B. Braun products. All product donation requests need to be received by B. Braun at least three (3) months before the donation is required. Please complete this form and submit it for processing; requests with missing information or supporting documentation will not be considered.

Requesting Organization Name

Requesting Organization Address Line 1

Requesting Organization Address Line 2

Requesting Organization City

Requesting Organization State

Requesting Organization Zip

Requesting Organization Country

Requesting Organization Tax ID Number

Requesting Organization Tax Status

Requesting Organization Type

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 Mission State

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 if 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 products are requested and if different than Organization or Principal investigator 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?

Non-Profit Designation Letter

IRS Form W9

Statement of Charitable Mission

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.

Requests and Documentation may also be

Emailed to:
GrantRequests@bbraunusa.com

Mailed to:
c/o B. Braun Medical Inc.
Attention: Corporate Compliance
824 Twelfth Avenue
Bethlehem PA, 18018

Compliance is what gives us the right to do business. At B. Braun, each of our employees is responsible for doing the right thing for the Company and for themselves. Acting in compliance allows us to continue to make a true difference for our customers and the patients they serve.

Product shipping information (may not be to a personal address) if products are requested and if different than Organization or Principal investigator information provided above:

Your request could not be submitted. Please try again.

Requests and Documentation may also be

Compliance is what gives us the right to do business. At B. Braun, each of our employees is responsible for doing the right thing for the Company and for themselves. Acting in compliance allows us to continue to make a true difference for our customers and the patients they serve.