Date:
Mr. Ms. Mrs.
Name:

If minor, state parents names:

Address:


City:   State:

Zip code:

Country:

Home telephone number:

E-mail:

Male Female

Birthday (month/day/year):

Current member of the IFOPA? (did you pay your dues this year?)


Item you want to buy with a LIFE Award:


Vendor providing the item, including contact information:


Total Cost:

Amount of LIFE Award you are requesting:

How much money have you collected towards this item:

How did you collect the money (saving, working, fundraising, donations):

Where else have you tried to get money to buy this item (health insurance, school, Department of Vocational Rehabilitation):

How will receiving a LIFE Award improve your quality of life or independence?

Thank you for applying, please press submit to give this form directly to the IFOPA.