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Donation Request Form
*
= Required Field
Request Information
Date of Request
Date of Event/Project
Agency Name
*
Location Address
Zip
City
State
-- Select A State --
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
DC
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Palau
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Puerto Rico
Rhode Island
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Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Mailing Address
Phone
*
Fax
Email
*
Contact Person
Title
VGM Employee Sponsor (if applicable)
Have you received funding from the VGM Group?
VGM Group:
Yes
No
If yes, what type of support have you received? Please provide dates, amounts, and types of support.
VGM:
Does your agency have a website?
Yes
No
If yes, please provide address:
Is this an annual event/program?
Yes
No
Amount of Request
*
$
Upload Request Forms
Acceptable Files: pdf, doc, docx, txt
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Services
Home Medical Equipment
VGM & Associates
U.S. Rehab
Government & Regulatory
VGM Government Relations
People for Quality Care
VGM National Competetive Bidding Services
Heartland Conference
Continuing Education
VGM Education
CE Solutions
CPAP Fulfillment
Orthotics & Prosthetics
Payer Network Access
Insurance
VGM Insurance
Pt1 Insurance Solutions
VGM Specialty Underwriters
Web
Printing
About VGM
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Senior Leadership
Employee Owned
Our Company
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