Helping Babies Breathe Purchase Order

To order Helping Babies Breathe (HBB) material, please fill in this form and email it . In case you do not have all the information at hand, you may send an incomplete form and provide the remaining information later.

Please direct any questions relating to this form or the HBB material in general to the email address above.

  1. Contact details
  2. Name of institutionsubmitting order:
  3. Contact person
  4. email: address of contact person
  5. Date of order submission
  1. Project information

The HBB material is available for countries identified by UNICEF as needing to advance Millennium Development Goal 4 (ref

  1. Please state in which country the HBB material will be used:
  2. Please provide a short description of the project:
  1. Order specification

Please state order quantity of the relevant materials in the table below:

Cat. no / Title / Price / Quantity
990-00033 / HBB Facilitator Set / USD 45
990-00133 / HBB Learner Workbooks (Qty. 20) / USD 18
990-00233 / HBB Facilitator Flip Chart Set / USD 27
  1. Shipping information
  1. Date products are needed at end destination:
  2. Shipping address:Name of consignee:

Street:

Post code:

City:

Country:

  1. Contact person: Name:

Phone:

Email:

  1. Freight forwarder:

Delivery terms are FCA (Incoterms 2000), Laerdal Warehouse Suzhou. This means we would like you to provide contact details to your freight forwarder, and we will coordinate shipments with them. We are happy to assist with planning for the shipment.

Name of your freight forwarder:

Contact information: Email:

Telephone:

I do not have a freight forwarder. Please arrange shipping through Laerdal’s

freight forwarder. The following shipping method is preferred:

Air express (door-to-door)

Air regular (door-to-airport)

Sea (door-to-seaport)

  1. Import documents:

Depending on shipping destination, there may be requirements to import licence, country of origin certificate, etc. that needs to be considered and planned before shipment. Please investigate the requirements that apply in the relevant country and provide the following information:

  1. Import licence

We hold an import licence

We will obtain an import licence before shipment arrives

Import licence is not required

We will investigate whether this is required

  1. Country of origin certificate

This is needed in order to import the order to the relevant country

Country of origin certificate is not required

We will investigate whether this is required

  1. Other documents

If other documents are required, please specify:

  1. Invoice details

Please provide the following information:

Name:

Street:

Post code:

City:

Country:

  1. Other comments

Please provide any other comments here:

For internal use:

Received

Accepted

PO#:

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