Professional Speaker Benefit Fund Application

Personal Information

Please provide the following information:
First Name:
Last Name:
Address (where the relief check should be sent):
City:
State:
Zipcode:
Phone:
Email:

Personal Information:

For payments to individuals, the IRS does require us to collect the Social Security number for report and audit purposes.
Social Security Number:

What is your current situation? (250 word limit). If additional space is needed, you can attach a Word document after you click submit.
E-Signature:
   - denotes required fields