#RESPONDLIKEJAKE

Application for Assistance

Apply Here:

Fill out the form below or download the paper application here.

Officer Name*
First Middle Last
Police Agency*
Rank*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Are you the applicant?*
- Yes
- No
Are they aware you nominated them for assistance?*
- Yes
- No
Contact Person*
Phone*
Reason for Assistance*
This can be you or anyone in your immediate family. Examples: Life changing medical diagnosis, house fire, loss of spouse or child, financial assistance due to loss of work, Covid 19, etc.
Immediate Needs*
Next Steps
1. The Board of Directors will review your application and notify you via phone or email as to the status of your application. Please understand we try to help as many families as possible, but are limited to the number of families we can help each year due to funding.
2. You will be contacted for a phone interview to help us understand your needs more if selected.
3. You may be asked to submit documentation of your needs. ie. medical diagnosis, insurance claim, death certificate, or past due bills.
4. The Board of Directors will vote on what capacity we can assist you and contact you again.
Confidentiality
JPRO will not release or share your personal information for any reason, unless you have specifically given us permission to do so for any purposes such as marketing, etc.
Signature*
I certify that my answers are true and complete to the best of my knowledge. I understand that false or misleading information in my application or interview may result in my application being dismissed.