Application for Assistance

I Am Requesting Assistance For Myself or Someone Else (Affiliated With AMO)

Date of Incident Creating the Need for Assistance

AMO Affiliation Of Individual In Need Of Assistance

Situation Creating Need For Assistance

Individual In Need of Assistance

Verification For Current / Previous

Employment / Affiliation With AMO

Last Name (AMO Employee, Current Contractor or Retiree)

First Name (AMO Employee, Current Contractor or Retiree)

Position/Title (AMO Employee, Current Contractor or Retiree)

Date: Begin of Service

Employment Status

AMO Point Of Contact Information

Current AMO GS-15/Executive Who Can Provide Employment Verification.

Last Name: Current AMO GS-15/Executive Contact

First Name: Current AMO GS-15/Executive Contact

Position/Title: Current AMO GS-15/Executive Contact

City: Current AMO GS-15/Executive's Office Location

State: Current AMO GS-15/Executive's Office Location

Email For Current AMO GS-15/Executive

Phone Number For Current AMO GS-15/Executive

By checking this box, you authorize the agency POC or designee to verify your stated AMO affiliation / employment.

Beneficiary Information

Last Name: Beneficiary

First Name: Beneficiary

Email: Beneficiary

Phone Number: Beneficiary

Please help us understand the specific circumstances surrounding the need for assistance. Provide as much detailed information as possible. The information you provide will assist in determining your eligibility under the current bylaws of our foundation:

By checking this box you authorize the sharing of all information above with AMFF and its advisory board to review, assess and determine the support we are able to provide. You also authorize us to contact you or your beneficiary for questions regarding your request for assistance.

Signature (Type Name in the Box Below)

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Checking this box affirms your understanding that the typed name above is the equivelent of your electronic signature.