MOUSE-AID APPLICATION FOR ASSISTANCE
Please note. This request will be presented to our officers for consideration. If approved by the officers it will be forwarded to the Board of Directors with all personal information hidden from their view. We will contact you as soon as a decision has been reached
All information will be kept confidential. No personal information will be shared with anyone other than the officers of mouse-aid. All decisions will be final.
NAME:_____________________________________________________________________________________
ADDRESS:__________________________________________________________________________________
CITY:______________________________________________________________________________________
STATE:_______________________________________________ ZIP:_____________________
EMAIL ADDRESS:_____________________________________________________________________________
TELEPHONE: ( ____ ) - ________________________________
BEST TIME TO CALL:__________ AM / PM
MOUSE-AID MEMBER NAME (required):____________________________________________________________
Please give us a brief statement about what type of assistance you are requesting.
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Is there a deadline date for this requested assistance? Y/N
If yes, what is the date? 00/00/2011
Y/N Do you allow us to use your story for fundraising purposes (your Mouse-aid username will be used in lieu of your real name... please create an account name for this purpose)
Please copy and email this form to Pogo@mouse-aid.org or Beth@mouse-aid.org