Loan Closet Application Form
ALS Association New Mexico Chapter
Date of Completion
Address, City, State, and Zip Code
Preferred method of contact
If other please explain below.
Is this application for you or family member?
Yes for me
Yes for Family Member
I have no association with someone who has ALS.
What type of assistance do you need?
Class 2 Power Chair
Class 3 Power Chair
Eye Gaze Technology
Do you have a prescription for requested items?
I`m not sure.
The ALS Association New Mexico Chapter loan closet is for the use and benefit of individuals diagnosed with ALS. Once equipment is no longer needed for said patient please to return to the ALS Association New Mexico Chapter. By clicking below you are agreeing to these terms and agreements and will return all equipment borrowed to the ALS Association New Mexico Chapter.
For further information or if you need assistance please call us at 505-323-6348 or emails us at email@example.com.
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