Reused and Exchanged Equipment Partnership REEP Networkapplication Form Please PRINT, COMPLETE

Reused and Exchanged Equipment Partnership REEP Network Application Form – Please PRINT, COMPLETE & FAX

Applicant Information

First name ______

Last name______

Title______

Program Name______

Address 1______

Address 2______

City______State______Zip______

County______

Telephone______

Email address______

Program Website______

Identify area(s) you serve (check all that apply):  Town/City

 County

 Statewide

 National

If multiple towns/cities or counties, please list: ______

______

Select the category of reuse that best describes your program (check all that apply):  Device exchange (matching donors to users without intervention, e.g., "classifieds" or online auctions)

 Device reassignment (making donated devices available to new users)

 Device recycling (breaking down unusable devices into spare parts or disposing of components in an environmentally appropriate manner)

 Device refurbishing (repairing and/or restoring donated devices to working order)

Please fax your registration form to Jamie A. Prioli, RESNA ATP EMAIL: [email protected] FAX: 215-204-6336 Or mail to REEP Network Institute on Disabilities at Temple University 1755 N 13th Street / Student Center, Room 411S Philadelphia, PA 19122

Reused and Exchanged Equipment Partnership Network

Are you a reuse program? TAKE OUR SURVEY NOW! www.surveymonkey.com/s/REEPPartners

Pennsylvania’s Initiative on Assistive Technology–PIAT Institute on Disabilities at Temple University, College of Education