NOMINEE APPLICATION

Thank you for your interest in submitting a Nominee application! Here at Bow-Up we are committed to making a lasting difference for individuals in the community who have been burdened by medical debt and medical related expenses. Nominee’s will need to show a true need for the help provided through Bow-Up. By applying, it does NOT guarantee the Nominee will be selected. Please note, if you are filling out this application to nominate someone in need, be sure to fill out the first three fields with YOUR information and the NOMINEES information will follow. If you would like more information or if you have any questions, please email us at bowup3d@gmail.com.

Your Name

First Name

Last Name

Your Email

Your Phone Number

(###)

###

####

Relationship to Nominee

Name of Nominee

First Name

Last Name

Nominee's Date of Birth

YYYY

Nominee's Phone Number

(###)

###

####

Name of Nominee's Employer

If Nominee is a minor, please list legal guardians employer

Nominee's Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Nominee's Email

Assistance Needed

Example: Medical bills, funds for lodging, gas or food during medical trips, etc..

About You:

Please provide a summary of why you are nominating an individual or seeking assistance from Bow-Up.