OFI Rural - Request for OCV1
This form is to request for Oxygen equipment.
It should ONLY be filled by NGOs/ Hospitals/ Volunteer Groups/ Clubs (referred to as Equipment Operator Partners or EOP)

1. OxygenforIndia.org (OFI), through its implementation partner Healthcubed, is considering requests to provide emergency oxygen cylinders / equipment on a fully returnable basis.
2. The focus is to support oxygen equipment needs in rural, small towns and peri-urban areas of India.
3. After a potential EOP applies using the form below, an OFI volunteer will reach out for additional details
4. Upon approval by OFI, Healthcubed and EOP will enter into an agreement wherein EOP commits to use the equipment shared for the benefit of needy patients, free of cost.
5. The EOP must pay a highly subsidised Refundable Deposit (liable to be forfeited on equipment not being returned/ misused) + nominal monthly cost.
a. Oxygen Cylinder (10L/ 15L): Refundable Deposit of Rs 5,000 per Cylinder + Healthcubed Cost Reimbursement of Rs 250 per month per Cylinder.
b. Oxygen Concentrator (5LPM): Refundable Deposit of Rs 15,000 per Concentrator + Healthcubed Cost Reimbursement of Rs 1000 per month per Concentrator.
6. The equipment shall be provided for an initial period of 2 months; mutually extendable, and must be returned upon the request of OFI.
7. For those looking at DONATION of Cylinders/Concentrators please DO NOT FILL this form. Please email us at ofi.ruralconnect@gmail.com and we shall connect you with other sources.

*A legal document with explaining the terms & conditions will be shared post verification
Name Of Organisation *
Email address of the organisation *
Web link, if any
Address of Organisation *
Pincode *
Were you active in providing healthcare support during 2020? If yes, how? *
What kind of support are you intending to provide to healthcare in 2021? Kindly mention if you would be partnering with any other NGOs/social services. *
Are you open to sharing OC-usage data with our implementation partner on a fortnightly/ monthly basis? *
Do you agree to return the Cylinders, concentrators ? *
Terms & Conditions regarding equipment return: This is captured as part of our lease agreement.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy