AVA Request Form

AVA Gift Card Requests

Employee First Name *

First Name

Employee Last Name *

Last Name

Email Address *

Employee Home Office *Please SelectAkron/CantonAltoonaAthensBellefontaineBloomingtonCambridgeCincinnati Columbus, INColumbus, OHColumbus/Newark HospiceCoshoctonCoshocton/Zanesville HospiceDaytonDayton HospiceDefianceDelaware/MarysvilleEdgewood/CarrolltonErie & Meadville HomecareErie & Meadville HospiceIndianapolisJeffersonville HospiceJohnstownJohnstown HospiceLancasterLawrenceburg HomecareLimaLima HospiceMarionMorgantown/Bridgeport/MoundsvilleMt. VernonNew PhiladelphiaNewarkPittsburghPittsburgh HospiceRMC (Worthington)Scottsburg/PaoliSomersetSt. Clairsville/BridgeportToledoUniontownWoodfield/MariettaZanesville

Type of Card *Please SelectAmazon (physical card or E-Gift Card NOW AVAILABLE!)Giant Eagle (physical card only)Kroger (physical card or E-Gift Card coming soon!)Sheetz (physical card only)Target (physical card or E-Gift Card NOW AVAILABLE!)Walmart (physical card or E-Gift Card NOW AVAILABLE!)MasterCard (E-Gift Card Only)TJ Maxx Brands (E-Gift Card Only)Kohl's (E-Gift Card Only)CVS (E-Gift Card Only)Lowes (E-Gift Card Only)Dick's Sporting Goods (E-Gift Card Only)JCPenney (E-Gift Card Only)Subway (E-Gift Card Only)

E-Gift/Physical Card *E-Gift Card

E-Gift/Physical Card *Physical Card

E-Gift/Physical Card *E-Gift CardPhysical Card

Points/Card Amount *Please Select25,000/$2549,000/$5073,000/$7596,000/$100121,000/$125143,000/$150168,000/$175190,000/$200

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