Air Purifier Request 
We are giving away free air purifiers on a first come first serve bases. Please fill out the form and we will reach out as supplies be come available.  
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Email *
Name: *
Address: *
Phone #: *
Email: *
Number of people living at this address:
Rooms on main level:
Rooms on 2ND level:
Rooms on 3RD level:
Do you have central air?
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By signing this Agreement, you agree to the following:
- There is no cost to participate. 
- Air purifiers will be used at the resident of record for the participant.
- Air purifiers will become the property of the participant.
- Air purifiers that have not been used for  period of 30 consecutive days.
- The participant authorizes VCAN to conduct status checks and inquires related to the use and functionality of air purifiers. 
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