Disasterreliefassistanceform

Individual

Business

First Name*

Last Name*

Email*

Phone *

Ext

Address Line 1*

Address Line 2

City*

State/Province*

Postal Code*

Country *

What is your current position in the collision industry / what do you do?

Business Name:*

Business City:*

Business State:*

Business Contact Name:*

Business Contact Phone:*

How did you hear about the Collision Industry Foundation? Please list the company/organization/publication or an individual's first/last name.*

What was the disaster (flooding, fire etc.)? And how have you been impacted by it?*

Are you currently employed?*

If you answered yes to the employment question, select one of these options:*

Any additional comments:

How could the Collision Industry Foundation assist you to get back to work if you are currently unable to work due to loss of tools, equipment etc.

What specific personal needs do you/ your family have that currently are not met?

What other benefits have you applied for due to this disaster?*

What other benefits have you received? *

1 -for CIF office use only

2 -for CIF office use only

3 -for CIF office use only

4 -for CIF office use only

By clicking I agree to the terms.