Received: Order #: Allocated: ACCOUNT INFORMATION COMPLETE DELIVERY ADDRESS. MAP Account #: Acct. Name: MISSION DESTINATION ORDERING PHYSICIAN

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1 Received: Order #: Allocated: Custom Order Shipping Instructions Form *3 week minimum required for delivery of all Custom Orders MAP International 4700 Glynco Parkway Brunswick, GA Customer Service: Fax: ACCOUNT INFORMATION MAP Account #: Acct. Name: MISSION DESTINATION Country: City/Region: Mission Hospital, Clinic or Project: COMPLETE DELIVERY ADDRESS ORDERING PHYSICIAN Residential Address Business Address Name: Phone: Check (note account name on check) Card #: Expiration Date: Security Code: Card Holder s Name (as it appears on card): _ Card Holder s Billing Address: PAYMENT TYPE Any additional donation to help support MAP s medicine programs is very much appreciated. If you wish to contribute, please indicate the extra amount here: $ Thank you!! Contact Name: Phone: Mission Team Departure Date: Mission Team Return Date: Requested Shipment Delivery Date: *If order is requested more than 1 month from Departure Date, please use Special Instructions section to explain. **Expedited service to meet deadline and deliveries to Alaska and Hawaii incur additional shipping charges. Shipping Mode: Air Freight UPS Ground SPECIAL INSTRUCTIONS SHIPPING INSTRUCTIONS Inland Freight/Truck Service * *Larger orders can be placed on wooden pallets and delivered by ground freight. Indicate under Special Instructions if this option is acceptable for your delivery address. This service may incur additional charges, but will ensure that large shipments arrive all together and at one time.

2 Custom Order Product Listing March 2019 *Please note that the Custom Order inventory changes on a daily basis, and therefore some of the items shown below may not be available at the exact time you place your order. Code # Description & Unit Size UM Exp Date Service Fee In U.S. $ Pharmaceuticals Minocycline HCI, Minocin 60cap BT 1/31/ Bisoprolol Fumarate 5mg Hydrochlorothiazide 6.25mg 1000tab BT 8/31/ Citalopram 20mg 100tab BT 2/29/ Citalopram 40mg, 100tab BT 2/29/ Norethindrone Acetate and Ethinyl Estradiol and Ferrous Fumarate, Blisovi Fe 1.5/30 (1.5mg/0.03mg) 3x28tab BX 10/31/ Empagliflozin 12.5mg/Metformin 1,000mg, Synjardy 14tab BT 1/30/ Pioglitazone 45mg 500tab BT 8/31/ Pioglitazone 45mg 90tab BT 8/31/ Pioglitazone 15mg 500tab BT 8/31/ Linagliptin 5mg, Tradjenta 30tab BT 3/31/ Acetylcysteine 500mg, Cetylev Effervescent tablets for Oral Solution, Lemon Mint 20tab BX 10/31/ P40002 Amoxicillin 250mg 100cap BT 5/31/ P40187 Amoxicillin 250mg 500 cap BT 7/31/ P40003 Amoxicillin Powder for Oral Suspension 125mg/5ml 80ml BT 1/31/ P40007 Fluconazole 100mg 30tab BT 6/30/ P40008 Atorvastatin Calcium 40mg 90tab BT 9/30/ P40009 Clotrimazole 1% Anti-Fungal Cream 30gm TB 4/30/ P40010 Levofloxacin Tablets 250mg 50tab BT 5/31/ P40011 Lisinopril 10mg 1,000tab BT 3/31/ P40012 Lisinopril Tablets 20mg 100tab BT 6/30/ P40013 Montelukast Sodium 4mg, Chewable 30tab BT 3/31/ P40014 Prednisone Tablets 10mg 21tab BX 3/31/ P40015 Amlodipine Besylate 10mg 90tab BT 2/28/ P40174 Amlodipine 10mg 1,000tab BT 7/31/ P40016 Sulfamethoxazole 400mg & Trimethoprim 80mg 500tab BT 10/31/ P40019 Losartan Potassium 100mg 90tab BT 11/30/ P40020 Rosuvastatin 40mg 30tab BT 7/31/ P40021 Simvastatin 40mg 1,000tab BT 9/30/ P40022 Simvastatin 40mg 90tab BT 7/31/ P40041 Ibuprofen 200mg 1,000tab BT 1/31/ P40051 Sulfamethoxazole 800mg & Trimethoprim 160mg 500tab BT 3/31/ Page 1 of 4 Qty Subtotals

3 P40063 Cephalexin 250mg 500cap BT 12/31/ P40073 Ciprofloxacin 500mg 100tab BT 12/31/ P40078 Cephalexin For Oral Suspension 250mg/5ml 100ml BT 5/31/ P40081 Spironolactone 50mg 500tab BT 6/30/ P40082 Aspirin 325mg 500tab BT 7/31/ P40086 Hydrochlorothiazide 25mg 1,000tab BT 4/30/ P40088 Hydrocortisone Cream 1%, Anti-Itch 28.4gm TB 5/31/ P40090 Metformin Hydrochloride 500mg 100tab BT 12/31/ P40171 Metformin Hydrochloride USP, 500mg 1,000tab BT 12/31/ P40093 Ranitidine 150mg 500tab BT 2/28/ P40095 Silver Sulfadiazine Cream, USP 1%, 50gm JR 1/31/ P40101 Acetaminophen 325mg, Mapap 1,000tab BT 9/30/ P40102 Acetaminophen 160mg/5ml, MAPAP Childrens 118ml BT 4/30/ P40104 Famotidine 20mg 100tab BT 4/30/ P40106 Azithromycin 250mg 3 x 6tab BX 9/30/ P40109 Amoxicillin 125mg, Chewable 100tab BT 8/31/ P40110 Triple Antibiotic Ointment 28.4gm TB 5/31/ P40113 Naproxen 250mg 100tab BT 5/31/ P40117 Clindamycin Hydrochloride 150mg 100cap BT 5/31/ P40118 Ibuprofen 800mg 100tab BT 4/30/ P40122 Acetaminophen 500mg 1,000tab BT 7/31/ P40123 Surgilube Surgical Lubricant, Sterile Bacteriostatic gm TB 9/30/ P40125 Doxycycline Hyclate 100mg 50cap BT 6/30/ P40127 Furosemide 20mg 100tab BT 9/30/ P40129 Hydrochlorothiazide 12.5mg 100tab BT 12/31/ P40130 Amlodipine Besylate 5mg 1,000tab BT 4/30/ P40131 Metoprolol Tartrate 25mg 100tab BT 6/30/ P40132 Spironolactone 25mg 100tab BT 4/30/ P40133 Carvedilol 25mg 100tab BT 5/31/ P40134 Carvedilol 6.25mg 100tab BT 7/31/ P40135 Carvedilol 3.125mg 100tab BT 10/31/ P40136 Clopidogrel 75mg 30tab BT 4/30/ P40137 Pravastatin Sodium 20mg 90tab BT 6/30/ P40138 Rosuvastatin Calcium 5mg 90tab BT 3/31/ P40139 Rosuvastatin Calcium 10mg 90tab BT 7/31/ P40141 Sawyer Point One Filter (0.1 Micron) Bucket Adapter Kit 1 kit EA NA P40149 Pharmacy Bags, Reclosable, 6 x 8 Zip-Tight 50ea RL NA P40150 Prescription Bag, 5 x 10, White 50ea RL NA P40151 Aspirin 81mg 1,000tab BT 6/30/ P40164 Azithromycin 500mg 30tab BT 7/31/ P40165 Metronidazole 500mg 100tab BT 8/31/ P40168 Glipizide 5mg 500tab BT 4/30/ P40169 Omeprazole 10mg, Delayed Release 100cap BT 2/28/ P40189 Prednisone 10mg 1,000 tab BT 9/30/ Vitamins/Replacement Preparations P40001 Oral Rehydration Salts 100schts EA 11/30/ P40018 Multi-Vitamins, Adult, Once Daily 1,000tab BT 2/28/ Page 2 of 4

4 P40034 Multi-Vitamins + Iron, Children s Chewable, Animal Shapes 250tab BT 4/30/ P40035 Multi-Vitamins, Adult w/iron. One Daily 1,000tab BT 5/31/ P40049 Multi-Vitamins, Children s Chewable, Animal Shapes 250tab BT 4/30/ P40055 Prenatal Multivitamins 100tab BT 3/31/ Supplies P10001 Sphygmomanometer, Aneroid Adult with Nylon Cuff 1ea EA NA P10002 Omron Professional Series Model 412 Dual-Head Stethoscope 1ea BX NA 8.57 P10025 Powder-Free Exam Gloves, Vinyl, Medium 100ea BX NA 4.46 P10028 Vinyl Exam Gloves, Powder-Free, Synthetic, Size Large 100ea BX NA 4.03 P40152 Exam Gloves, Medium, MediGuard ES, Powder Free, Nitrile 100ea BX NA Exam Gloves, Nitrile, Powder-Free, Non-Sterile, X-Small 200ea BX NA Exam Gloves, Nitrile, Powder-Free, Non-Sterile, Small 200ea BX NA Exam Gloves, Nitrile, Powder-Free, Non-Sterile, Medium 200ea BX NA Exam Gloves, Nitrile, Powder-Free, Non-Sterile, Large 200ea BX NA Exam Gloves, Nitrile, Powder-Free, Non-Sterile, X-Large 200 BX NA Eyeglasses, used prescription, assorted sizes, shapes and colors 500pr BX NA Assorted Eyeglasses & accessories Approx 75pcs BX NA RL Hand Masker 12"x360ft 1MIL Masking Plastic, 3M 12rl CS NA RL Hand Masker 9"x360ft 1mil Masking Plastic, 3M 12rl CS NA RL Hand Masker 6"x360ft 1MIL Masking Plastic, 3M 12rl CS NA RL Painters Tape 1.41" x 45 yds, Safe Release Plantium 32roll CS NA RL Respirator, 3M SaNding/Fiberglass Valved 2ea PK NA Body Balm, Le Petit Marseillais Shea Butter, Sweet Almond & Argan Oil 250mL 3pk PK 11/1/ Sunscreen SPF 50, Neutrogena Lotion Broad Spectrum 147ml BT 12/9/ Syringe 60cc Luer-Lok Tip, sterile 20ea PK 7/31/ Syringe 10ml Luer-Lok Tip, Sterile 200ea BX 7/31/ Needle 18g x 1", Regular Bevel 100ea BX 7/31/ Insulin Syringe 29 Gauge 0.5cc 1/2" 100ea BX 2/11/ Courtsey Surgical Pack 1 EA NA Particulate Respirator, 3M 9105 Vflex N95 20ea BX 6/20/ Knee Brace, Hinged, 3M Ace, Adjustable 1ea BX NA Wrist brace, 3M Futuro, Adjustable-Moderate Support, Left/Right 1ea BX NA Thumb Stabilizer, 3M Futuro, Small/Medium 1ea BX NA Deluxe Wrist Stabalizer, 3M Futuro, Small/Medium, Left Hand 1ea BX NA Hand Support Glove, Ace Energizing, Small/Medium 1rs BX NA Wrist Stabalizer, 3M Futuro, Large/XLarge, Right Wrist 1ea BX NA Deluxe Wrist Stabalizer, 3M Futuro, S/M Right Hand 1ea BX NA Deluxe wrist stabalizer, Ace, L/XL left wrist 1ea BX NA Deluxe Wrist Stabalizer, Ace, S/M Left Hand 1ea BX NA Deluxe wrist stabalizer, Ace, S/M right hand 1ea BX NA Hand/Wrist Compression Glove-Small/Medium, 3M Futuro 1ea BX NA Night wrist support, Futuro, adjustable 1 ea BX NA Ankle Stabilizer, Futuro Sport Deluxe, Adjustable 1ea BX NA Ankle Support, Adjustable, 3M Futuro 1ea BX NA Ace Head Band White 1ea PK NA 0.50 Page 3 of 4

5 Compression Shorts w/protective Cup, Ace Youth L/XL 1ea PK NA Sheer Knee Highs for Women, Mild Compression, Futuro, Small Nude 1ea BX NA Earmuff, passive ear muffs 1 ea EA NA ACE Compression Knee Support, Small 1ea BX NA Compression Knee Support, Large, Ace 1ea BX NA Knee Stabilizer, Adjustable, 3M Futuro 1ea BX NA Knee Support, 3M Futuro, Adjustable 1ea BX NA Knee Support, 3M Futuro, Large 1ea BX NA Knee Support, 3M Futuro, Medium 1ea BX NA Daily Pill Holder, MediPlanner Deluxe 1ea BX NA Body Wash, Le Petit Marseiliais-Orange Blossom 400ml BT 5/23/ Shower Creme, Le Petit Marseiliais-Cotton Milk & Poppy 400ml BT NA Shower Creme, Le Petit Marseiliais-Orange Blossom, 650ml BT 3/24/ Insolated Junior Cooler Bag 9.25 x 8.25 x 7" 1 EA NA Patient Slippers, Toddler, Aqua 48pairs CS NS Patient Slippers, Medium (Men s 6-7, Womens 5-7), Green 48p CS NS Patient Slippers, Adult-Medium (Mens 6-7/Womens 5-7), Blue 48p CS NS Patient Slippers, Adult-Large (Mens 8-9/Womens 8-10), Beige 48p CS NS Slippers, Patient, Adult-XXL(Mens 11+/Womens 12+), Gray 48p CS NS FDS Intimate + Body Cleansing Wash Tangering Blossom 296ml BT NA Portion Control Plate, Stay Fit 1 EA NA Plush Goodnight Kisses Owl 36 ea BX NA Goodnight Kisses Children's Book 36 ea BX NA 0.72 Complete your order at MAP's Customer Service team can also be reached by telephone at ; Monday thru Friday - 8am to 5pm (Eastern Time) Page 4 of 4