Batch Device Request Form

Partnering Facility

Select which facility you are part of:

Title

Title of the main point of contact who will be managing the devices

First Name

Last Name

Cell Phone Number

(###)

###

####

Facility Address

Requested Date of Delivery

YYYY

Estimated date of return

YYYY

Number of Devices

Safety and Return of Devices

I hereby confirm that I assume all responsibility for the devices and will ensure the devices are managed and stored safely, sanitized between uses, and returned to Connected Canadians.

Delivery instructions

Batch Device Request Form

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