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Contact & Residence

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Name

Phone

Address

City

State

Zip

Phone (secondary)

Length of time residing in Interior Alaska

Physician Verification

Physician

Physician's Phone

Physician's verification is requred and will need to be attached at the bottom of the form.

Your Request

Please describe the purpose of requsted funds.

Amount requested:

Certification

By providing my signature below, I authorize the IACA Board of Directors to contact my physician to verify that I am currently undergoing cancer treatment. I certify that I have resided in Interior Alaska for at least 6 months. I certify that I do not have the services for which I am requesting financial assistance available through any federal or state agency, medical insurance, or assistance program. I understand that all decisions of the IACA are final and assistance is determined based on qualification, verification, and availability of funds.

Your Signature

Physician Verification is required.

Please upload your verification below:

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Document

Upload File: Verification

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