Stair Lift Donation Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
States we are Currently Serving
*
MN
IL
WI
IN
MI
MO
OH
OK
KS
NE
SD
ND
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What Brand/Model Stair Lift are you looking to Donate?
*
Please Select
Acorn 130, 180 (Curved)
Bruno 3000, 3050, 2010
Handicare 1100
Would you like a Tax Voucher for your Donation sent to the email above?
*
Yes
No
What time of day is best for Pickup?
*
8-10am
10-1pm
1-4pm
4-6pm
Submit
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