<p> CPAP ASSISTANCE PROGRAM</p><p> o f</p><p> t h e American Sleep Apnea Association 1717 Pennsylvania Ave, NW ● Suite 1025 ● Washington, DC 20006 ● Telephone/Facsimile: 888-293-3650</p><p>Donation Evaluation Form</p><p>If you have a new or gently used CPAP machine you wish to donate to the CPAP Assistance Program (CAP), please fill in the following form, email it to us as an attachment at [email protected] or print and fax it to us at 888-293-3650. We will be in touch with shipping instructions, PLEASE DO NOT SHIP DEVICES TO THE ASAA HEADQURTERS IN WASHINGTON, D.C. </p><p>If you have difficulty faxing or questions, contact us at 1-888-293-3650, Option 1 or include them in the comment box.</p><p>Name: </p><p>Street Address: </p><p>City: State: Z i p c od e: _ Email: Phone #: </p><p>Machine Manufacturer: □ Phillip Respironics Model: □ System One □ ResMed □ S9 □ Fisher & Paykel Healthcare □ Icon Hours Used (estimate or give months of use if you don’t know exactly): </p><p>Accessories: □ carry case □ new and unused filters □ new and unused tubing □ new and unused mask in original sealed packaging</p><p>Comments:</p><p>CAP Donor Page 1 Revised: 8/14</p>