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