Application for Equipment Assistance Name*Date of Birth* MM DD YYYY Agency*Agency Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Cell Number*Email* Agency Director*May we contact your direct supervisor? Yes Supervisor Name*Supervisor Phone*Supervisor Email* Please briefly explain you need for Equipment Assistance with in your agency:*All requests are subject to approval by the FROM Board of Directors and may require further information and documentation from applicant or agency. All request are Confidential. Equipment Policy: All request for Equipment must be through the agency requesting the equipment. Equipment Request will not be considered for Individuals only. All request are confidential. Emergency Request: If your request is an emergency, please contact us immediately. EmailThis field is for validation purposes and should be left unchanged. Donate to Support Apply For Assistance