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Electronic Application
Eligibility & Use of Gifts
PDF Application
Questions?
Schedule/Timeline
Contact
Map & Directions
Donate
Corporate Giving
Donors
Personal Giving
Project Specific Donations
Events
Annual Golf Outing
CFA Foundation Kick-Off Breakfast
Hold Your Own Fundraiser
Strike for Hope Bowling Tournament
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Electronic Application
If you meet the eligibility requirements and wish to apply for foundation assistance, please fill out the form below.
Applicant Information
Worker's Full Name
*
First
Last
Worker's Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Cell Phone
Number of dependents (including minor children of the applicant)
*
Employer at Time of Injury
*
Employer Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Name of Person Submitting
*
Phone
*
Email
*
Relationship to Worker
Who should we contact for additional information? (Enter their full name.)
Relationship to Worker
Phone
Email
*
Incident / Injury Information
Was this a construction or facilities maintenance-related incident at an Indiana jobsite?
*
Yes
No
If you answered no, please explain.
Was the applicant fatally injured?
*
Yes
No
If you answered no, please describe the injury.
Date of Incident
*
Location of Incident (please include name of facility if applicable)
*
How has this injury/fatality affected the worker and his or her family?
*
Please use this space for any additional information you feel the CFA Foundation Board should know
Please attach any documents relative to this application for CFA Foundation assistance.
Accepted file types: jpg, pdf.
Verification of Information
Verification
*
By checking this box, I certify the information on this application is factually correct to the best of my knowledge.
Captcha
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