Equipment Donation Form

Thank you for Donating your used equipment to Easy Does It. Our Wheelchair Repair Program relies on donated parts to keep the cost of repairs affordable, your Power Chair or Medical Equipment will make a difference in the lives of our clients. Please let us know what type of your equipment you're donating, and whether or not you'd like us to pick it up for you.

Page 1

Contact Info

First Name

Last Name

E-mail Address

Phone Number

Would you like to subscribe to our mailing list?

Yes, add me to your mailing list

We need your contact information to arrange a pickup for your Equipment Donation. You will not receive Marketing Communications without giving us permission.

Equipment Information

Chair Make

Chair Model

Is the Device Fully Operational?

Fully Functional and No Cosmetic DamageFully Functional with Cosmetic DamageDevice is Inoperable, Parts Only

Page 2

Delivery Information

How would you like to Donate your Equipment?

Pick up the Device for MeI'll bring the Device to You

Device Pickup

Street Address

City

Zip

Once we've confirmed that we can use your equipment. We'll reach out to schedule a time to pickup your donation.

Please wait to hear from a Team Member before dropping off your donation

Thanks for choosing to drop off your equipment donation. Be advised that our visiting our offices is only possible with an appointment. So please wait to hear from a Team Member before visiting. We'll contact you shortly to confirm that we can accept your donation and arrange a time for drop off. Click Submit to Continue.