Free911CellPhones.com ISMA Collections Form

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Free Cell Phone Program
Participation Form

The ISMA Free 911 Cell Phone Program, in partnership with Free911CellPhones.com will collect, re-program and distribute used 911-capable cell phones to victims of domestic violence who cannot afford a phone or indigent and elderly persons, based on medical necessity.

Please complete and submit it online or print this page and fax it to 317.261.2234.

I would like to be a designated collection point for cell phone donations. (Open to anyone.)

I would like to be a designated collection and distribution point.
Please note: In order to be able to distribute phones through this program to individuals in need,
you must be affiliated with one of the following:

Physician
Medical practice
Clinic or Outpatient facility

Hospital
Domestic violence shelter
Local Health Department

I would like to request sets of promotional materials.
(each set includes 1 poster, 1 table top display, and 1 public instruction sheet)

* Required Information

What we ask for each phone collected…

Wipe it down.
Clear phone memory
Include charger, battery and any accessories
Collection box should be in a secure high-traffic area.
Store phones in a secure area.
You will be contacted on a regular basis to schedule phone pick up or you may send an email to free911cellphones.com

What we do with the phones…

Make sure phones are in working condition and evaluate
Dismantle and clean
Recharge or replace batteries
Repackage with battery and charger
Distribute based on need from established sites

*First Name

*Last Name

Middle Initial

*Email

Name Suffix

Name Prefix

Degree

MD DO RN
Other:

Department

*Organization

*Address

*City

*State

*ZIP Code

*Office Phone

Fax

For questions call Jill Bruce at the ISMA 1-800-257-4762 or 317-261-2060
or email her at jbruce@ismanet.org

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