WISHMASTERS

WISH APPLICATION FORM:

Please read the Wish Granting Policies with recipient requirements and wish restrictions found below prior to completing an application

A. Please complete this section if you are requesting a wish for another person.

Wish Nominator Name:

Phone Number:

Alternate Phone Number:

Street Address:

City:

Zip Code:

State:

E-Mail Address:

Buisness Name:

Title:

Buisness Address:

Buisness Phone Number:

Do you accept calls at work?

YES

This applicant is known to me because:

B. Wishmasters Nominee Information: (The person for whom the wish is requested.)

Wish Nominee Name:

Birth Date:

Street Address:

City:

State:

Zip:

Phone Number:

Cell Phone Number:

E-Mail Address:

Annual Income (estimated):

How did you hear about Wishmasters?

C. Please describe your wish.

D. Please explain why this wish is special to the recipient.

E. List any physical limitations or special needs.

F. Certification:

By signing below, I acknowledge that the acceptance by Wishmasters of this application form does not constitute an agreement by Wishmasters to fulfill my wish request. If Wishmasters is able to fulfill the wish request described above, a Wishmasters representative will contact me. Furthermore, I certify that the wish recipient meets all inital eligibility criteria as described on page 3 of this agreement and declare that all of the information given by me in this application is true and complete to the best of my knowledge. I also agree to inform Wishmasters in a timely manner if any information contained in this application changes.

Signature:

Date:

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