Equipment Request Form

Loan Closet Request Form

ALS New Mexico has the largest equipment loan closet for ALS families in the state. Families are encouraged to access this program which is free of charge. Once the equipment is requested, care service team will reach out to coordinate the pick and drop off of loaned equipment. Making the process as easy and stress-free for our families.
Borrower Name*

First NameLast Name
Is this application for you or family member?*
Date of Request*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Equipment

Mobility itemMeal KitCommunication DeviceRamp/AccessibilityTransportationFinancial SupportHome Modification RequestNutrition SupportUnsure/Need helpOther
If need help or Other, please describe to best of ability
ALS New Mexico loan closet is for the use and benefit of individuals diagnosed with ALS ONLY. Once the equipment is no longer needed for the individual living with ALS kindly return borrowed items promptly. The return of ALL borrowed items is imperative for ALS New Mexico to continue to provide life-changing care.

Items that DO NOT need to be returned:

- Bath Items

- Respiratory Equipment
Borrower Signature
Additional Details/Comments
Authorized Name

First NameLast Name
Authorized Signature
Should be Empty:

Loan Closet Request Form