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WE ENDURE

Application

T.W.C.F. Application

Please complete the form below

Name

First Name

Last Name

Date of Birth

Diagnosis

Diagnosis Date

Doctor

Treatment Facility

Type of Treatment

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Phone

(###)

###

####

Current Employer

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Phone

(###)

###

####

Position

Salary per Year

Supervisor's Name

Other Income Source Amount

Monthly Expenses_ Utilities (Electric, Gas, Water)

Monthly Expenses_ Auto Expense (Gas, Repairs. Insurance)

Monthly Expenses_ Phone

Monthly Expenses_ Medical

Monthly Expenses_ Medications

Monthly Expenses_ Dental

Monthly Expenses_ Vision

Monthly Expenses_ Insurance

Monthly Expenses_ Food

Monthly Expenses_ Clothing

Monthly Expenses_ Child Care/Elder Care

Has money been raised on behalf of the applicant?

If yes, how much?

Has there been assistance from other organization?

If yes, name Organization

Financial Assistance Requested_ (Please Priortize)

What impact has this diagnosis had on your current income or financial situation?

What other financial resources do you have access to, or are you of that may assist you with treatment or other related costs?

Explanation of Emergency Situation_

Due to our own family’s experience we have found the local cancer support groups directly help families emotionally and financially. This is why we donate a portion of every purchase to Mary’s Team Whiskey Cancer Foundation. Thank you for your support so we can help families in their time of need.

To nominate a local cancer support group email the name, location, and any contact information to info@team-whiskey.com.

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T.W.C.F. Application

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Application

T.W.C.F. Application

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