Believe 271 Application For answers to your questions about this application, please contact: B271 President Brian Palmer (315) 790-8038 B271 VP Brian McQueen (315) 552-8245 B271 Recording Secretary Betsy Schwertfeger (315) 725-6404 * Required Field Basic Information Full Name: (first, middle initial, last) * Mailing Address: * City, State and Zip: * County: * Home Phone: * Cell Phone: * Birthdate: (month, day, year) * Family Information Spouse's Name: (first, last) * Wedding Date: (month, day, year) * Do you have any children under the age of 18? * YesNo If yes, how many? * Names and ages of children (under age 18): * Volunteer Fire Department or Auxiliary Information What Volunteer Fire Department or Auxiliary do you presently belong to? * Are you a current member? * YesNo How many years have you been with this Volunteer Fire Department or Auxiliary? * What titles or positions have you held with this Volunteer Fire Department or Auxiliary? * What other Volunteer Fire Departments or Auxiliaries have you belonged to and for how many years? * Current Volunteer Fire Department Chief's Name: * Current Volunteer Fire Department Chief's Phone Number (home or cell): * Current Volunteer Fire Department or Auxiliary President's Name: * Current Volunteer Fire Department or Auxiliary President's Phone Number: * Employment Information Current Employer: * Career or Job Title: * Years with this Employer: * Do you work full or part time? * Full TimePart Time If retired, who did you work for and for how long?: What was your job title(s) for this employer? Do you plan to continue to work during your treatments: * YesNo Does your spouse work? * YesNo Spouse’s place of employment: * Spouse’s Career or Job Title: * Will spouse continue to work during your treatments? * YesNo Medical Diagnosis What is your medical diagnosis? * If cancer, what stage are you? * Any additional information in regards to your medical diagnosis you would like to include: * What form of treatment(s) is planned? * What is the frequency of treatments and for how long? * Where will treatments take place? (hospital, city, state) * Financial Support Do you have medical insurance? * YesNo How much will your medical insurance cover in regards to your diagnosis and treatment (approximate percentage of coverage)? * What other sources of financial support do you have? (personal savings, benefit, donations, etc.) * Other Who was the person that informed you of our Foundation? * Please write down any information that could better help us understand the applicant's illness. * NOTE: ALL INFORMATION MUST BE COMPLETED BEFORE SUBMISSION.