Hole In One Foundation Donation Request
Name (Person submitting application)
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date
-
Month
-
Day
Year
Date
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Name (Person in need of assistance)
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
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Employment
Currently employed
Employed but currently unable to work due to medical reasons
Unemployed
Disabled
Retired
Self
Other
Please explain in detail the major life-changing event that has caused the incurred financial burden.
What cost have been or will What costs will not be covered by insurance?
What costs will not be covered by insurance be covered by insurance?
Type of assistance you're in need of (ex. monetary donation, gas cards, food, clothing, etc.) Please explain in detail how the donation will be used .
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Has there been a benefit held for this cause and if so, what is the total of monetary donations received? (include all bank accounts, online funding sites ex. gofundme, local benefits, all money raised for cause)
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