Bulk Donation of Mobility Aids - Manufacturers or Distributors

"Bulk donations" refers to large donations of a single mobility aid. This type of donation is typically provided by the manufacturer or distributor of a specific mobility aid.

If your company would like to make a bulk donation of mobility aids that are appropriate for the Haiti Mobility Aid Relief Effort, please complete the following form. Once you have submitted the form online, please also print the form and include it in the shipment of your donation.

COMPANY AND CONTACT INFORMATION

Prefix:

* Contact First Name:

* Contact Last Name:

Company:

* Street Address 1:

Street Address 2:

* City:

* Country:

* Region:

* Zip Code:

* Contact Email:

* Re-enter mail:

Contact Primary
Phone Number:

Contact Secondary
Phone Number:

Comments:

How did you
learn about this?

MOBILITY AID INFORMATION

Please select the product(s) and quantity(s) that you intend to donate

Crutches

Walkers

Wheelchairs

Adult Crutches

Adult Walkers

Adult Wheelchairs

Pediatric Crutches

Pediatric Walkers

Pediatric Wheelchairs

SHIPPING INSTRUCTIONS

Package all donated products appropriately and ship to:	Center for International Rehabilitation 350 West Mart Center - C2 level Suite 115 Chicago, IL 60654 312.280.4970
If you have any questions or concerns, please feel free to write to us at support@iconsinmed.org