CONTACT INFORMATION
*Organization Name:
*Business Address:
*City:
*Telephone Number:
*Website:
*Contact Name:
*Contact Title:
*Email:
*Contact Telephone:
*Are you a member of the AT Network? If no, JOIN NOW!
Select One
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No
DEVICE 1
*Total Amount Requested: $
*Device to be Repaired/Refurbished:
*Category
Select One Category for Device 1
Daily Living
Environmental Adaptations
Hearing
Learning, Cognition & Developmental
Mobility, Seating, Position
Vehicle Modification & Transportation
Vision
Recreation, Sports, Leisure
Speech Communications
Other
*Parts or repairs to be funded:
*Brief (200 words or less) description of repairs needed:
*MSRP of device: $
*Date device was donated to your program:
*Will the device be:
Select One
Donated to a consumer
Provided for a small fee
If the consumer is paying for the device, what will the consumer pay?
*Manufacturer's Suggested Retail Price (What consumer would pay for the device if new.
If you are unable to find the exact price, use the value of a comparable device.
Using estimates is acceptable when exact pricing information is not available.)
DEVICE 2
Total Amount Requested: $
Device to be Repaired/Refurbished:
Category
Select One Category for Device 2
Daily Living
Environmental Adaptations
Hearing
Learning, Cognition & Developmental
Mobility, Seating, Position
Vehicle Modification & Transportation
Vision
Recreation, Sports, Leisure
Speech Communications
Other
Parts or repairs to be funded:
Brief (200 words or less) description of repairs needed:
MSRP of device: $
Date device was donated to your program:
Will the device be:
Select One
Donated to a consumer
Provided for a small fee
If the consumer is paying for the device, what will the consumer pay?
DEVICE 3
Total Amount Requested: $
Device to be Repaired/Refurbished:
Category
Select One Category for Device 3
Daily Living
Environmental Adaptations
Hearing
Learning, Cognition & Developmental
Mobility, Seating, Position
Vehicle Modification & Transportation
Vision
Recreation, Sports, Leisure
Speech Communications
Other
Parts or repairs to be funded:
Brief (200 words or less) description of repairs needed:
MSRP of device: $
Date device was donated to your program:
Will the device be:
Select One
Donated to a consumer
Provided for a small fee
If the consumer is paying for the device, what will the consumer pay?
DEVICE 4
Total Amount Requested: $
Device to be Repaired/Refurbished:
Category
Select One Category for Device 4
Daily Living
Environmental Adaptations
Hearing
Learning, Cognition & Developmental
Mobility, Seating, Position
Vehicle Modification & Transportation
Vision
Recreation, Sports, Leisure
Speech Communications
Other
Parts or repairs to be funded:
Brief (200 words or less) description of repairs needed:
MSRP of device: $
Date device was donated to your program:
Will the device be:
Select One
Donated to a consumer
Provided for a small fee
If the consumer is paying for the device, what will the consumer pay?
DEVICE 5
Total Amount Requested: $
Device to be Repaired/Refurbished:
Category
Select One Category for Device 5
Daily Living
Environmental Adaptations
Hearing
Learning, Cognition & Developmental
Mobility, Seating, Position
Vehicle Modification & Transportation
Vision
Recreation, Sports, Leisure
Speech Communications
Other
Parts or repairs to be funded:
Brief (200 words or less) description of repairs needed:
MSRP of device: $
Date device was donated to your program:
Will the device be:
Select One
Donated to a consumer
Provided for a small fee
If the consumer is paying for the device, what will the consumer pay?
Upload Your Copy of IRS Determination Letter:
After submitting an online application, the Reuse and Finance Coordinator will respond with a tracking number for each device submitted for repair. We reserve the right to deny applications for any reason. For first time applicants, please also provide a copy of IRS determination letter of tax-exempt status.
Upload copy of IRS determination letter
*I certify that the device(s) repaired is not owned by an individual with a disability, but will be reassigned to a new owner. Type your name in the field box.
