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Tennessee Fire Fighters Emergency Relief Fund - Request for Assistance
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Applicants Email
example@example.com
Phone #
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
Martial Status
Please Select
Single
Married
Divorced
Number of Dependents
Fire Dept. Employer
Date of Employment
-
Month
-
Day
Year
Date
Active or Retired
Please Select
Active
Retired
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If, IAFF Member, Local #
Ph#
Format: (000) 000-0000.
Address
City
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you eligible for any other insurance or monetary relief?
Please Select
Yes
No
if yes please describe below:
Please give a detailed reason for your request. You may use the back of the form or attach your reason.
Applicant Signature
Date
-
Month
-
Day
Year
Date
Applicant, Please Fill out the Contact Information to verify you work for a Department or a Member of the IAFF
If you are a Union Member, Fill out "Union contact box Only"
Department Contact Person
Rank:
Email ( Email will be sent to verify)
example@example.com
Contact Verification Signature
You are stating that the applicant is a member of the Fire Department listed above
Employment Verification: Date Verified
-
Month
-
Day
Year
Date
If not in the Union please put "N/A" in this section
Union Contact Person
Email ( Email will be sent to verify)
example@example.com
Title:
Position in the Union
IAFF Verification Signature
You are stating that the applicant is a member of the IAFF
IAFF Member Verification: Date Verified
-
Month
-
Day
Year
Date
Board Title
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
For Fire Fighter Emergency Relief Board Only
Signature
Verified by(print)
Submit
Submit
Should be Empty: