Simply copy and paste the application below to a new Word document or Notepad. Fill in your information, print it out and send by email or postal mail, your completed application form to:
Mike Bell, Hunters Helping Hunters
509 Joyner Road
Waynesboro, GA 30830
Name ________________________Phone number ( ) _______________
Address: _______________________ City ____________ State ___ Zip ________
Your E-mail address (optional) ______________ Age _____ Date of Birth ___/ ___/___
Did you hunt last year? YES or NO If no, last year you hunted _____
Which state issued your license? _______________ Date issued:____________
Please supply license Number: ____________________
If available, please attach at photocopy of your hunting license.
How did you hear about Hunters Helping Hunters (HHH)?
Why are you requesting financial assistance?
Did the police, an Insurance Agency, or similar agency investigate this incident, which created
this need? _________ If so, state Agency.s name and address
(If there is a copy of a Police incident. / accident report, please attach a copy)
As a result of this incident, did you or your family suffer any financial loss or burden? Explain:
Please explain or fully describe your situation and how any loss occurred.( use additional sheets if
Amount of assistance requested $ __________. 00, from Hunters Helping Hunters
If granted, how is this assistance in full or part going to be used?
To whom will the assistance go?
(Cash payment will not be made directly to any applicant, only to creditors or businesses deemed owing)
Attach copies of bills, estimates, or other proof of indebtedness.
Are you currently employed? ______ If so, Employer ____________________
Address of employer ______________________Phone Number ______________
Number of years employed? _________Average monthly earnings $ _______.00.
Is the person out of work as a result of this situation? ______
Last date of work if currently unemployed: ___/____/___
Return date to wok, if known: ___/___/___
Was this loss or incident covered by any insurance ________ if yes, type of insurance and
Name of carrier _____________________________________________________
Are you collecting or have you applied for any other form of assistance? _________
If yes, Name of Assistance and dollar amount of Assistance
Is there any pending litigation over this incident, or have you been in contact with an attorney
____________if yes, give name, address and phone number?
Do you own your own home? ____ if so, number of years remaining on loan? ____
Monthly mortgage or rent payment_____________
If renting or leasing home list Landlord name, address, and telephone number
How long have you lived in current residence? __________Years
Do you own a vehicle? ________If yes, list year, type and model of all vehicles
Total monthly car payment? _______
Total cost of Monthly Utilities (electric, gas, water, sewer) ______________
Do you have a checking account? ________ Total Balance_$________. 00
Do you have a saving account? _______ Total Balance_$________. 00
Name and address of Bank _______________________________________________________
Do you own a Credit Card?______, if so list all credit card (Visa, Master Card)
Total amount of Monthly Credit Card bill? $ ________
I ______________________________________hereby authorize the members, committees,
board members and employees of ( HHH ) to fully investigate all information I have supplied in
the pervious pages, which are in accordance with my request for financial assistance.
Furthermore in signing this waiver, I authorize Hunters Helping Hunters to obtain my personal
financial information, verification of employment, verification of my loss and any other
information they, HHH, may deem necessary in order to process and investigate my request. In
addition, I agree to hold harmless Hunting Helping Hunters (HHH) it employees, members of the
board of directors, its membership or committees, jointly and severely from any action or form
of action arising out of my applying for assistance through Hunters Helping Hunters HHH). I
also agree to hold harmless any institution or person supplying Hunters Helping Hunters with
information pertaining to this request.
I fully understand that this application may be granted or denied at any time with or without
Cause by the board of directors of Hunters Helping Hunters (HHH).
In signing this release of information and waiver, I swear that the facts contained in the previous
pages are true and correct to be best of my knowledge and recollection. I am also aware that
swearing to false statements could make me guilty of a crime.
( signature )
Hunters Helping Hunters, Inc, hereby agrees that all information contained in this
application and resulting investigation shall remain confidential. All information will be
solely used for official HHH business.