Application

TJ & Friends Foundation, Inc.
Ride to Live, LIve to Ride, Live Strong

APPLICATION FOR DONATION
Submit this completed application along with the required documentation to PO Box 6161, Elberton, GA 30635.

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Name _________________________________________________________________

Physical address:

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Street City State Zip

Mailing address:

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Street City State Zip

Contact numbers:

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Home phone Cell phone

Email address: ________________________________________________________________________

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Cancer diagnosis:

Type of cancer: ___________________________________________________________________________

Date of Diagnosis: ________________________________________________________________________

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Statement of need:

Describe your need for this monetary donation.

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Statement of involvement in your community:

Describe your involvement in the community in which you live in.

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Please attach the following documents with your application. Failure to submit these items will classify your application
NOT COMPLETE, there fore will not be reviewed until the required documents are submitted.

Proof of cancer diagnosis:

You must attach a signed and notarized statement from your attending physician, currently treating you for cancer, confirming cancer diagnosis.
DO NOT SEND PATHOLOGY REPORTS OR OTHER MEDICAL DOCUMENTS!!

Proof of residency:

You must attach a copy of local tax documents or a signed and notarized statement from your landlord proving you have been a resident
of one of the following counties for at least one year prior to your diagnosis; Elbert, Hart, Franklin, Madison, Lincoln, Oglethorpe, or Wilkes County.
DO NOT SEND STATE OR FEDERAL TAX DOCUMENTS.

Poof of citizenship to the United States:

You must attach a certified copy of your birth certificate, or other documentation in order to prove that you are a citizen of the United States.

By signing below I promise that all information contained in and attached to this application is true, and I release this information
for the soul use of TJ & Friends Foundation, Inc. in order to recieve the donation. If applicant is under age 18 or elderly, a family
member or guardian signs as witness.

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Signature of applicant

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Witness

I will also sign below giving the TJ & Friends Foundation, Inc. the permission to photograph me and/or my loved ones for
use on website, news papers, DVDs, or other means of advertisment in order to spread the word about our local foundation.

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Signature of applicant

Do not write below this line

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Date received completed application__________________________________

Date reviewed by board of directors___________________________________

Accepted______________________ Declined______________________

Date of donation______________________________ check #____________________