Contact Information

First Name*

Last Name*

Email Address*

Business Phone*

Job Role

Company/Organization Information

Company*

Address 1*

Address 2

Country*

State or Province*

Zip or Postal Code*

Are you a Veteran Affairs Medical Center?*

Yes

Product Trade-In Information and Quantity

Donated or Scrapped Chair Manufacturer*:*

Donated or Scrapped Chair Model*:*

Quantity*

Please check this box if you are donating or scrapping multiple makes and models

Additional Donated Scrapped Chair Manufacturer, Model and Quantity:

Ex: Midmark, 630 Procedure Chair, 10

Electronic Signature Agreement*

I agree to use an electronic signature and certify that I have donated or scrapped the product as required for this rebate.*

By typing your name below, you are signing this agreement electronically. You agree you electronic signature is the legal equivalent of your manual signature.

Electronic Signature*

Email Opt-In

Please check this box if you would like to be notified via email regarding product information, promotional opportunities and other Midmark news and updates.

address3