AbleNet AT Donation Request Application
Thank you for your interest in a donation of Assistive Technology products. Requests are reviewed by our team and decisions are based on alignment with our mission, demonstrated need, and available inventory. You will receive a response within 2 weeks of submission.
Organization name
*
First Name
*
Last Name
*
Email
*
Mobile Phone
*
Format: (000) 000-0000.
Address
*
State
Please Select
I live outside of the United States
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Organization mission and proof of non-profit or school status
*
Please use attachment section below if needed.
Include attachment
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Requested product(s)
*
Please describe how the product(s) will be used and the expected impact
*
Please provide a brief explanation of financial need (e.g., budget constraints, lack of funding)
*
By selecting yes below, you are stating your agreement to not resell or distribute the product for profit.
*
Yes
By selecting yes below, you are stating your agreement to provide an impact statement, testimonial, and/or photos within 3 months of receiving the donation.
*
Yes
By selecting yes below, you are giving consent to use name, likeness and written content in AbleNet promotional and marketing materials.
*
Yes
By clicking Submit, you agree to our
Privacy Policy
&
Terms of Use
Submit
Should be Empty: