Miami Dancers Relief Fund Application

MIAMI DANCERS RELIEF FUND

APPLICATION FORM
Contact Information
Title:
Name*

First NameLast Name
Birth Date

MonthDayYear
Marital Status:*

SingleMarriedOther
E-mail*
Phone*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long have you lived in your given address?*

0-1 Year1-2 Years3-4 Years5+ Years
Professional Information
Dance Occupation*
Dancer, Choreographer, Agent etc.
Agency (if any)*
Years of experience*

0-1 Year1-2 Years3-4 Years5+ Years
Gross monthly income*
Monthly rent/mortgage*
Other expenses*
Average amount of monthly expenses
Comments:
Include other info you would like to share
I authorize the responsible party for Miami Dancers Relief Fund [ MDRF ] to utilize this information solely in consideration as a recipient of the aforementioned. This information, as well as that provided by me in the application, will be referred to in connection with this application for MDRF ONLY**

YES
I hereby agree that the information given is true, accurate and complete as of the date of this application submission. **

YES
Should be Empty:

MIAMI DANCERS RELIEF FUND