Blue Line Foundation - Application

About us

Blue Line Foundation Application for Review

Name:

Street Address:

City:

State: Zip:

Telephone #:

Date of Birth:

Social Sec. #:

Drivers Lic. #:

Marital Status:

# of Children:

Annual Salary:

Your Salary: Spouse Salary:

Date of Injury:

Were you on duty when the injury occurred?

Brief Description of Injury:

Have you been injured before in the line of duty?

If Yes, please explain:

If you have not been injured, but are experiencing an extreme hardship, please explain your situation below:

Please list your top four (4) needs below in order of priority. (Examples: house payment, car payment, medical bills, etc.):

Need

Payment Amount

1.
2.
3.
4.

Please list three (3) references who would comment on your injury or hardship. (Chief, Sheriff, etc.)

Reference

Telephone Number

1.
2.
3.

**	Please send any official reports and newspaper articles concerning your situation	**

***	It is VERY IMPORTANT that we receive a picture of you (in uniform, if possible) for us to place on the Blue Line Foundation website	***

Additional information or questions regarding this application should be directed to:

Geri Hege
Blue Line Foundation, Inc.
Email: GeriHege@yahoo.com