If you would like to print out a hard copy, you may click on the link at the very bottom and a PDF document will automatically downlod to your computer. Then you may print it out and mail it in to our address in Philadelphia. This webform is a bit easier and much faster, but the PDF is there if you prefer. Please complete all fields to the best of your ability. For any mandatory field that is not applicable to you, enter "none" and continue. A copy of your completed application will be emailed to you. Make sure we have some way to contact you in order to consider your application. All applications must be received by July 1st, including supporting documentation (DD214, photo ID, Letters of recommendation, etc.). Awards will be decided upon by August 1st. If you are 'nominating' a friend or family member, assume all instances of "you" are actually the person you hope will receive a gift.

Personal Information

Keep your information confidential?: * select...YesNo

If "Yes," we will only share your data with partners who help us process your application.

First name: *

Last Name: *

Birthdate: *

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To confirm your age, or maybe so we can send you a card...

Street Address 1:

Street Address 2:

City, State: *

Zip Code:

Email: *

Phone Number: *

Social Networking:

Do you use Facebook, Myspace, or others? How can we find you?

Parent/Guardian Name: *

Same as Personal Address?: * select...YesNo

(If Yes, leave following address fields blank)

Parent/Guardian Address 1:

Parent/Guardian Address 2:

City, State:

Zip Code:

Parent/Guardian Phone: *

Education

Last Educational Institution Attended: *

Institution Address 1:

Institution Address 2:

City, State:

Zip Code:

Date Graduated or Last Day Attended: *

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Focus/Major:

Highest Level of Education Completed: * select...GEDHigh School DiplomaAssociate DegreeBachelor Degree

Academic Interest: *

What subject most interests you?

Educational Goals: * select...High School DiplomaAssociate DegreeBachelor DegreeGraduate StudiesOther (Please explain)

Other Educational Goals:

First in your family to seek higher education?: * select...YesNoI don't know

Extracurricular Activities

Organization 1:

Position:

Date Served From:

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Date Served To:

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Organization 2:

Position:

Date Served From:

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Date Served To:

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Organization 3:

Position:

Date Served From:

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Date Served To:

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Honors & Awards

Title 1:

Awarding Organization:

Date Awarded:

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Title 2:

Awarding Organization:

Date Awarded:

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Title 3:

Awarding Organization:

Date Awarded:

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References

Name 1:

Relationship:

Phone:

Email:

Name 2:

Relationship:

Phone:

Email:

Name 3:

Relationship:

Phone:

Email:

Military Background

Current Military unit:

Or last unit assigned

City, State:

If applicable

Branch of Service: * select...Dept. of DefenseArmyNavyMarinesAir ForceCoast GuardNo Affiliation

Status: * Active DutyReserve - DrillingNational Guard (Indicate State)Veteran/Prior Service (Indicate length of service)Retired MilitaryInactive Reserve/Guard - IRR (Indicate Remaining MSO)Service Academy (Indicate Branch)ROTC (Indicate Branch and School Year)J-ROTC (Indicate Year)Delayed Entry Program - DEPOther Training Program (Please Explain)Considering EnlistingSpouse of Service Member (Indicate Active Duty or Reserve)Spouse of Veteran/Prior ServiceSpouse of RetireeOther Military Dependent (Please Explain)Other Family Member (Please Explain)Government EmployeeDefense ContractorMilitary EnthusiastNo Affiliation

Explanations:

If your selection requires elaboration, please use this space to do that

Essay Questions

Describe your Journey: *

How did you come to the point you are at now, and how has your spirituality interacted with your military experience?

Describe your Need: *

How can we be of assistance, and in what ways have you exhausted all other options?

Is this an immediate need?: * select...YesNo

If Yes, Please Explain:

Briefly describe the urgency of your need and when it must be met by.

Describe your Vision: *

How would this gift fit into your future hopes and dreams?

Supporting Documents:

Upload your DD214, Letters of Recommendation, or photo ID (jpegs only, up to 1.5Mb). Proof of identity is required for consideration, and Letters or Recommendation must be mailed in or scanned with a signature and contact information for the person supplying them. You are not required to upload a file now; you can mail copies to our PO Box or electronically send scanned documents to our email address. All documents must be postmarked prior to July 1st.

Permission: *

I give Centurion's Purse permission to publish/share publicly my responses as they seek to assist others

I give Centurion's Purse permission to use my responses but ask that my name be concealed to protect my identity

I do not give Centurion's Purse permission to share my responses publicly

How did you hear about us?:

Knowing this helps us reach more folks in need

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