Weather Radio Campaign Application
This application is meant to help you apply for a free weather radio + batteries. It is available to the following counties: Cumberland, Fentress, Putnam, Overton, & White in Upper Cumberland, Tennessee. Keep in mind: this application is also available via paper means; if you prefer that, please call us to have it emailed or mailed to you.
Date
*
-
Month
-
Day
Year
Date
Please tell us your first & last name:
*
First Name
Last Name
Please tell us your home address (the place where you personally live):
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please tell us your primary phone number:
*
Please enter a valid phone number.
Please tell us your primary email (this is how we will primarily contact you):
*
example@example.com
How many people live in your household currently?
*
Please describe why this weather radio would benefit your household:
*
Have you personally received a weather radio from us in the past?
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Yes
No
Not sure
Please upload a clear copy of your current ID. We will accept a picture as long as it is clear and shows the entire document. (We need this to prove your identity and address. We do not share this. This online form is HIPPA secure.)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a clear copy of your most recent month's bank statement, all pages. We will accept pictures as long as it is clear and shows the entire document; we will need each page. (We need this to prove your need. We do not share this. This online form is HIPPA secure.) If you do not have a bank account, we will be unable to verify your need and cannot approve your application.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Should you be approved for a weather radio, please check the county (or counties) you would like the radio to be programmed for:
*
Cumberland
Fentress
Overton
Putnam
White
Other
Do you understand the following statements? (1) You must submit this application along with all requested documents to be considered eligible. (2) We have a limited supply of weather radios each year. This means submission of this application does not mean you are approved to receive a weather radio. (3) If you want your radio shipped to you (instead of picking it up from our office in Crossville), you will be invoiced for shipping. (4) Should you not turn in the correct documents, pages are missing, or the documents are unclear/incomplete, your application will NOT be processed; you will have 5 days from the time we reach out to you via email for this to be fixed. After that, you will have to submit a new application.
*
I Have Read & Do Understand This.
Submit
Should be Empty: