Date of application: ___________________________________________________________

Name of organization to which an AED and/or AED's will be granted. Please list exact legal name.

_________________________________________________________________________


Address of organization: ________________________________________________________

_________________________________________________________________________

Telephone number:_________________________     Fax:___________________________

E-mail: __________________________________________________

Executive Director: __________________________________________________________

Contact person and title (if not executive director): ________________________________

Is your agency a Health and Human Service organization?
(Yes or No):_________________________________________________________________

Is your organization a NYS IRS recognized 501(c)(3) not-for-profit for at least 5 years?:
(yes or no): ________________________________________________________________

Please include IRS issued Tax Exempt form with completed application and Waiver forms (3 total). Please note, you must be 501c3 to participate.

Federal ID #:_______________________________________________________________

Charity Registration #:_______________________________________________________

Attach list of participating certified programs

Applying organization’s Executive Director’s
Signature:_______________________________________Date:______________________

National Foundation for Human Potential authorized signature:_______________________

Please Email or Fax us this page to 516.870.1620 or 12forlifenys@familyres.org