Form

Phase 1 Application - JWF Artist Relief Fund

Fill out this form to apply for individual Artist Relief Fund campaign, assistance and grant services.
Todays Date *

- Month - Day Year
Applicant Name - (as it appears on Social Security Card) *

First Name Middle Name Last Name
Applicant Professional Name a/k/a - (If different from above)

First Name Middle Name Last Name

Home Address *

Mailing Address (If different from Home Address)

Phone Number *

- Area Code Phone Number
E-mail *
How many years have you worked in the music industry? *
In what capacity? *
Brief Bio Section
Are you currently employed outside of the music industry? *

YES NO
Please describe your medical situation and request for assistance: *
Important

We need to verify the contact info of the person filling out the form. In many cases the person in need of assistance is unable to. Please fill in all required information below even if you have already done so in the previous section.
Who Is filling out this form? *

I am the person in need of assistance I am applying on behalf of the person in need of assistance
Name of person filling out this form *

First Name Last Name
Relationship to applicant? *
E-mail of person filling out this form *
CONFIRMATION OF SUBMISSION WILL BE SENT TO THIS EMAIL ADDRESS
Phone Number of person filling out this form *

- Area Code Phone Number
I hereby certify that I have answered the foregoing questions to the best of my ability. The facts herein stated are true and I understand that any misrepresentation of this information may disqualify me for any assistance from The Jeremy Wilson Foundation *

I agree
Should be Empty:

Phase 1 Application - JWF Artist Relief Fund