Personal Assistive Device Request Form "*" indicates required fields To receive equipment, you are required to be a member of the Langley Pos-Abilities Society. Membership entails a small annual fee of $25.* Are you a Langley Pos-Abilities Society member? Yes No To receive equipment, there is also a $50 PAD Fee for all equipment request applications. Have you already paid the PAD fee?* Yes No Please visit this page to become a member of Langley Pos-Abilities Society: Membership Application FormName* First Last Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Telephone*Email How did you hear about us?DetailsPlease give us as many details as possible so we can match you up with an appropriate piece of equipment, eg. “Powerchair for tall heavy adult, or “Scooter for small adult." We will be contacting you to discuss your request.We take your privacy very seriously. Your information is not shared with any other agency or organization without your written consent.Payment Method* Interac e-transfer Credit Card Sending an e-transfer via your online banking system is easy. 1. Log in to your financial institution's online or mobile banking and navigate to Interac e-Transfer Send Money. 2. Select the account you would like funds transferred from. 3. Add or select "Langley Pos-Abilities Society" and e-mail address "zosia@pos-abilities.org" 4. Type in the specified amount you are sending, along with a personalized message such as: "PAD Fee" in the message area. 5. Click "Submit" button.PAD Application Fee Price: Credit CardConfiguration Required: To use the Square field, please configure your Square Settings.CommentsThis field is for validation purposes and should be left unchanged. Δ