NKBA Disaster Relief Form

NKBA Member Application for Assistance

To be eligible for assistance you must an NKBA Member and must reside in one of the affected areas.

All applicants must have an active NKBA Membership prior to August 25, 2017.

Please fill out and submit the information below and an NKBA representative will be in contact with you shortly. If you have any questions, please contact Julie Figiel at JFigiel@nkba.org or by phone at 800.843.6522 x 3746.

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* 1. Personal Information

Name

NKBA Id #: (For ID assistance call 800.843.6522)

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Company Information

Company Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 3. Assistance Need:

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* 4. Please describe in detail your need based on damage from the recent disaster in your area:

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* 5. NKBA Use Only: