Recipient Registration Form
Complete the following application to establish yourself as a recipient of medical goods, supplies, and equipment from Silver Lace, Inc.  The Approval Process may take 24-72 hours.  You will receive additional instruction via email once Approved.

Please Note: A registration fee is required to be paid prior to first pick-up.  Your approval email will provide further details.

This form is intended for those who are able to attend pick-up events and/or schedule deliveries.
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Organization
Please provide the name of the Organization that you represent.
First Name *
Last Name *
Phone Number *
Email Address *
Street Address *
Street Address 2
Suite, Building, etc.
City *
State *
Zip Code *
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This form was created inside of Silver Lace, Inc..