Stair Lift Donation Form

Stair Lift Donation Form
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Please select your City. (*States below are the current Cities we pick-up in*)*

MinnesotaWisconsinChicagoIndianapolisKansas CityClevelandNebraskaSt. LouisSouth DakotaDetroitPittsburghPhiladelphiaCincinnatiNorth DakotaBoston
Email
example@example.com
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
What Brand/Model Stair Lift are you looking to Donate?*
Would you like a Tax Voucher for your Donation sent to the email above?*

YesNo
Attach a photo of the stair lift
How did you hear about us?*
Remember to check your email for responses!
Should be Empty: