MiLOOP Mission Pre-Qualification Form

1. Date of Mission/Training *This question is required.

Start Date This question requires a valid date format of MM/DD/YYYY.

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End Date This question requires a valid date format of MM/DD/YYYY.

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2. Requesting Organization *This question is required.

3. Organization Contact Person *This question is required.

First Name

Last Name

Title

Street Address

Apt/Suite/Office

City

State

Zip

Country

Email Address

Phone Number

4. Country Where Mission/Training will Occur *This question is required.

5. Length of Mission Trip *This question is required.

6. In-Country Mission Trip Contact *This question is required.

First Name

Last Name

Title

Organization Name

Email Address

Phone Number

7. *This question is required.

MiLOOP Units Requested

MiLOOP Type

8. Number of Expected Surgeries *This question is required.

Who will conduct the surgical training?

*This question is required.

First Name

Last Name

Title

Organization Name

Email Address

Phone Number

10. Number of In-Country Doctors Participating *This question is required.

11. Has permission been obtained to import surgical supplies? *This question is required.

12. Please describe your planned follow-up: *This question is required.