Retired - Agency Request Form

Agency Request Form
This form has been retired. Please use the updated form available here: https://www.repairbank.org/get-support.

More about the program at www.repairbank.org
Agency information
Agency Name*
Contact Name*

First NameLast Name
Contact Email*
example@example.com
Contact Phone Number*
Please enter a valid phone number.
Can you pick up items at our SoDo location or do you need a drop off at client’s location?*

We can pick up items from SoDo, SeattleWe need a drop off and can pay a feeWe need a drop off but do not have resources to cover a feeOther
How did you hear about us?
Client Name*

First NameLast Name
Client’s Country of Origin
Move-in date (leave today's date if the client has already moved in)*

MonthDayYear
Date
Client's Address (will be used in case of a delivery) *

Street Address

Street Address Line 2

CityState

Zip Code
Zip Code*
Zip Code
Number of People in the Family*
Number of Rooms in New Housing*
Please tell us a little about the family- what is their story?*
Desired Style (optional; see examples below)
Hidden Furniture List
Beds (if yes, how many and what size, do they need a mattress, is bunk bed preferred?)*

NoYes
Crib or other kids' furniture (if yes, what and how many?)*

NoYes
Dining table (if yes, how big, ex. for 4 people, for 8 people, do they prefer a bar height table?)*

NoYes
Dining chairs (if yes, how many, do they prefer bar height chairs??)*

NoYes
Dresser or Chest (if yes, how many?)*

NoYes
Couch, Sofa, or Loveseat (if yes, how many and how big?)*

NoYes
Lounge chair, armchair, side chair, ottoman (if yes, what and how many?)*

NoYes
Coffee table, side table, nightstand, TV stand, console table (if yes, what and how many?)*

NoYes
Office table, office chair, file cabinet (if yes, what and how many?)*

NoYes
Floor or table Lamp (if yes, what and how many)*

NoYes
Bookcase, standing shelf, shoe rack (if yes, what and how many?)*

NoYes
Mirror or wall art (if yes, what and how many?)*

NoYes
Other Requests (optional)
Should be Empty:

Agency Request Form

Agency information