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DISASTER RELIEF PROJECT APPLICATION
First Name
Middle Name
Last Name
Address Line 1
Address Line 2
City
State
Zip Code
Country
Daytime Phone() -
Evening Phone() -
Fax() -
E-mail Address
Brief description of need
# of adults in household
Annual household income
Do you have insurance to cover the need?
If yes, please identify the insurance company and policy limits
Please provide a brief description of any efforts you have taken to try to meet your need

Please note that this is only an initial application for assistance.  If Ten Minas is considering helping you, we will be in touch to request more information specific to your particular need and to explain the process to you in more detail.  Ten Minas reserves the right, in its sole discretion, to accept or decline any application.  If, upon further investigation, we learn that any material misrepresentation has been made in the application process, that will be grounds for immediate cancellation of any efforts at assistance.  Thank you.
(c) 2010 Ten Minas Ministries, Inc., P.O. Box 827, Havre de Grace, MD 21078; (410) 935-0701