"QUICK CHECK PROGRAM" APPLICATION FORM

Our "Quick Check Program" Application

(Please, completely fill out before submitting.)

* Indicates required field

Requestor's Name *

First

Last

Requestor's Title *

Requestor's Email *

Supervisor's Name *

First

Last

Organization's Name *

Organization's Phone Number *

Organization's MAILING Address (Fill out Carefully!!!) *

Line 1

Line 2

City

State

Zip Code

Country

Organization's PHYSICAL Address *

Line 1

Line 2

City

State

Zip Code

Country

Requestor's Relationship to Patient *

Patient's Primary TERMINAL Diagnosis *

Describe Item(s) or Service(s) for Purchase. [Please EXCLUDE medical items, utilities, rent, mortgage, and funeral expenses] *

Please Include Website Link(s) for requested Item(s)/Service(s) IF ANY. *

Reason For Purchase *

Anticipated Cost *

PLEASE explain why Patient AND other Adult Family Members are NOT able to purchase the requested Item(s)/Service(s). *

****Please Explain Why your Organization is NOT paying for the requested Item(s)/Service(s). *

Please CERTIFY to the following by check-marking each statement: *

Said item(s) and service(s) will be IMMEDIATELY PURCHASED with TILT's funds AND TIMELY DELIVERED to your patient. ALL the information in your application is TRUE and ACCURATE.

For TILT's Grant-Writing Use Only: *

Minority? Female? Male?

Requestor's Signature (Please Type) *

Date of Request *

Submit

Our "Quick Check Program" Application(Please, completely fill out before submitting.)

Our "Quick Check Program" Application

(Please, completely fill out before submitting.)