Equipment Donation Questionnaire HiddenNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.Your Name(Required) First Last Your Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your Phone(Required)Your Email Address(Required) Email Address Confirm Email Address Are/Were you or a family member served by ALS United Greater Chicago?(Required) Yes No If yes, which Care Service Coordinator served the family? Joumana Baroody Peggy O’Connor Gema Ramos Kellie Branch-Dircks Brianna Neal Please list any and all equipment that you would like to donate to ALS United Greater Chicago below. Be as specific as possible, especially in regards to how old the equipment is, what condition it is in, and the make and model of the equipment.(Required)Is the equipment from the VA?(Required) Yes No Is equipment pick up address different than above? If so, please provide location of pick up: Additional Information: