Stop Drop and Push- Grant Application

PERSONAL INFORMATION

First Name *

Last Name *

Address

Street Address *

City *

State *

Postal Code *

Phone *

Date of birth *

Alternate Phone

Email *

Current Occupation *

Number of Dependents *

How did you hear about SDP Alternative Therapy:

Who Referred You:

What therapy Are you applying for (if known):

What dates would you like to attend (if know):

FINANCIAL INFORMATION

Net Paycheck #1

Monthly Amount

How Long Received?

Net Paycheck #2

Monthly Amount

How Long Received?

Soc. Sec. /Pension

Monthly Amount

How Long Received?

VA Disability

Monthly Amount

How Long Received?

Monthly Expenses

REFERENCES

Reference 1

Name (Reference 1) *

First

Last *

Last

Phone (Reference 1) *

Reference 2

Name (Reference 2) *

First

Last *

Last

Phone (Reference 2) *

Upload DD214 *

VA Disability Award Letter

TALENT RELEASE FORM

Consent

I agree to the privacy policy. *

I authorize USA Homeownership Foundation, Inc. DBA Veterans Association of Real Estate Professionals (VAREP) and the Stop, Drop and Push Campaign to make use of my appearance if awarded a grant. This may include video or photo. These videos and photos are used to bring further awareness about the campaign and may be used at fundraising events to help us continue to raise funds for Veterans. They may also be used on our website and on social media. I understand that I am to receive no compensation for this appearance. VAREP shall have complete ownership of the program. I give VAREP the right to use my name, likeness and biographical material to publicize the program and the services of VAREP to create awareness and increasing sustainable housing among the military and veteran communities. VAREP may: 1. Photograph me and record my voice and likeness for the purpose of the production mentioned above, whether by film, videotape, magnetic tape, digitally or otherwise; 2. Make copies of the photographs and recordings so made; 3. Use my name and likeness for the purposes of education, promotion or advertising of the sale or trading in the photographs, recordings and any copies so made. I further understand the master tape remains the property of VAREP and that there will be no restrictions on the number of times that my name and likeness may be used.

Consent

I agree to the privacy policy. *

Privacy Policy VAREP is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all information shared both orally and in writing will be managed within legal and ethical considerations. Release of your information to third parties We will not disclose any of the information that we collect, as described above, to any third parties.

To the best of my knowledge, I hereby certify that the information provided on this application is complete, accurate, and true. I agree and understand that by submitting this application I authorize VAREP to send me emails, newsletters, and customer satisfaction surveys.