Application – Trimmers Assistance Program

Assistance Application

Name

Address

City, State/Province/ Post Code

Country

Email

Telephone

HTA Member

Years Trimming

Reason for application

Date of injury/illness

Expected Recovery Time

Have you received medical treatment?

Yes No

Please explain:

What assistance is being requested?

Trimming/Scheduling Monetary Assistance Both Other

Trimming/Scheduling

I would prefer:

Local trimmers Non-local trimmers

Monetary Assistance

.Other Support Received:

Insurance Workers Compensation Government Subsidy/Support Other None

Other Assistance Requested: Please explain

Individual completing form

Email for individual completing form

Telephone of individual completing form

Is there anything else you would like the Committee to know?

Board of Directors

Philip Spence, Chair
Richard West, Treasurer
Mark Burwell, Secretary

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Name

Email