This field is hidden when viewing the formDate of Application MM slash DD slash YYYY PART I: Recipient InformationName First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PART II: Medical InformationAre you currently undergoing dialysis?* Yes No Which facility?What is the name of your Social Worker?Have you had your first pre-transplant appointment?* Yes No Which medical facility?Are you actively scheduling appointments to help move forward with the pre-transplant workup?* Yes No When is your next appointment? MM slash DD slash YYYY Please tell us about your dialysis story.*If you have already received a gas card in the past and are re-applying for a new gas card, tell us how your last appointment with the transplant doctor went.Part IV. Additional InformationSubmitter’s Name* First Last Relationship to Recipient*Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email I stipulate that the information included in this application is true to the best of my knowledge. Further, I understand that the presence of inaccurate information in this application could result in the need for the re-evaluation of this application on the part of JJ’s Legacy. If inaccurate statements can be proven to be the result of negligence or intentional inaccuracies on my part, JJ’s Legacy may be entitled to a full refund of any funds awarded. Signature*Signature Date MM slash DD slash YYYY After review of your application, you will be notified if you qualify for a $50 gas card. Should you require additional funding for travel to/from your medical center for future pre-transplant related appointments, you may apply again and receive up to 3 gas cards per person per year.
