The B.A.N.C. Foundation(tm)
INJURED BIKERS AND NEEDED CHILDREN
A 501 (c) 3 NONPROFIT CHARITY FOR
214 CECIL AVE. SPRING LAKE, NC 28390
Ph: (910)-551-1161---Fax: (910)-497-0188
Website----www.thebikersandneedychildrenfoundation.com
E-Mail----thebancfoundation@yahoo.com
Application for Assistance
Everyone that ask for assistance must fill out an application,  there will be no exceptions. So PLEASE fill out the application
and mail, email, or fax it to the address or fax number above. Please print legibly so we can read you information. If you can
not print this application please call the phone number above and we will talk to you and mail you one.
Someone at The B.A.N.C. Foundation will contact you as soon as we receive your application.

Name:                                                                                                                        

Address:                                                                 
  City:                                    State:                              Zip:                           

E-mail Address:                                                                                                                                                                            

Phone:                                                                  

How many people live in the Home:         How many are Children:          

Employer:                                                                                                                                                                                   

Address:                                                                   
 City:                                   State:                              Zip:                           

Phone:                                                                   

Yearly Income:             Where does your income come from. List all income:                                                                             

                                                                                                                                                               

Name of 3 References (Can not be related to Applicate;

Name:                                                                                                                           
                                                                                                                                                                                                                                                     
Address:                                                                    City:                                 State:                                Zip:                           

Phone:                                                                    

Name
:                                                                                                                                                                                                                                         
                                                                                                                                                                                         
Address:                                                                    City:                                 State:                                Zip:                           

Phone:                                                                    

Name
:                                                                                                                                                                                                                                         
                                                                                                                                                                                          
Address:                                                                    City:                                 State:                                Zip:                           

Phone:                                                                    

Injury that is keeping you from working:                                                                                                                                     
                                                                                                                                       

How was injury incurred?                                                                                                                                                            
                                                                                                                                       

How long do you expect to be out of work?                                                                                                                                 
                                                                                                                                       

Copy of Medical Report.                                                                                                                                                             

Copy of Police report if a traffic accident.                                                                                                                                   

Explanation as to what kind of assistance is needed:                                                                                                                    
                                                                                                                                       
Mortgage Payment:                                                               

Rent:                                                                                     

Utilities Company and amount owed: Water:                                                              Power:                                                      

Phone:                                                                                  

Food:                                                                                    

Other:                                                                                  

Sign Name:                                                                            Date: