Med Equip. Form 2017-11-09T00:01:04+00:00
Valley Charities

DBA: turn A leaf Thrift Store

400 N. Yenlo

Wasilla, Alaska 99654

Phone: (907) 376-5708

Fax: (907) 376-5792

Date Equipment Issued: *
Responsible Person: *
Responsible Person's Phone Number*
Planned Returned Date*
revised return date
User Gender:
User Age Range:*
User's full name*
Mailing Address
I have read and I understand the listed guidelines. Furthermore, I agree to the terms and conditions of these guidelines. *