Equipment Request/Release Form

Borrower Name*

First NameLast Name

Is this application for you or family member?*

Date of Request*

Date

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Type of Equipment

Reason for Use

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

By signing below, You agree to these terms and agreements and will return all equipment borrowed to ALS New Mexico. The borrower acknowledges that he/she is responsible for any damage to the items/equipment.

Borrower Signature

Additional Details/Comments

Authorized Name

First NameLast Name

Authorized Signature

Loan Closet Request Form