Apply AM I ELIGIBLE? I am currently serving or have served in the military.I am currently employed in Wyoming as a first responder (police or fire/rescue).Veteran police officer or fire/rescueOther If 'Other' above, describe your eligibility CONTACT INFORMATION First NameLast Name StreetCityStateALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip TelephoneEmail Address Date Of BirthGenderMaleFemale SERVICE/EMPLOYMENT INFORMATION BRANCH OF SERVICE/ FIRST RESPONDER STATUS: Dates of Service/Employment: BeginningEnd Service Status:ActiveRetiredReserveOther Please upload a record of service, proof of employment, discharge papers, or proof of eligibility. ADDITIONAL INFORMATION How much are you requesting? Have you received any other donations thus far?YesNo Describe your situation and why you are seeking funds. Would you be willing to share your story?YesNo INJURY INFORMATION (if applicable) DATE OF INJURY TYPE OF INJURY Please upload any supporting documentation to demonstrate financial need. ELIGIBILITY VALIDATION Name of Superior Officer Or Supervisor Contact Information of Supervisor Your Printed NameToday's Date I certify that the information I am submitting is true and correct. By marking this box, I acknowledge this action constitutes my legal electronic signature! "Our objective is to provide assistance to Wyoming veterans/active-duty military, first responder, veteran police officers or fire/rescue and their immediate families who are in need of financial assistance in times of medical or personal crisis."
