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

No

Product Donation Information and Quantity

Please select which chair type you are trading in*

Manual Examination Tables

Powered Examination Chairs

Manual Tables Quantity*

If none, enter 0

Powered Tables Quantity*

If none, enter 0

Any known quality issues with product?*

Yes

No

If yes, please explain:

Please explain issues

Logistics Information

Name of Shipping Contact*

Shipping Contact Phone Number*

Shipping Contact Email Address*

Address of Product*

Country (Shipping)*

State or Province (Shipping)*

Zip or Postal Code (Shipping)*

Are you able to provide transportation for your donation to a destination within the United States?*

Yes

No

Are you able to provide labor to load donated tables?*

Yes

No

Is a lift gate required to get product on truck?*

Yes

No

How will the product be shipped?*

On Pallets

Floor Loaded

Other

If other, please explain:

Shipping detials

Additional Information

Ex: More than one location

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.

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