Native
Village Home PageLink Center Foundation
An All-Volunteer 501(c)3 Colorado Non-Profit Organization
P.O. Box 2253 ~ Longmont, CO 80502-2253
Voice Mail: 303-554-5363 ~ Office Phone: 888-220-1653 Toll Free
Email: admin@linkcenterfoundation.org
Donations also accepted at: www.LinkCenterFoundation.org or through Network for Good
Elders
Assistance Program Confidential Registration Application
Full Name: _________________________________________________ Birth Date: ___________
Spouse’s Full Name: _________________________________________ Birth Date: ___________
Address: ________________________________________________________________________
City, State, and Zip: _______________________________________________________________
Phone: __________________________________________________________________________
Email or Other Phone: _____________________________________________________________
Income Sources and Amount Per
Month: _____________________________________________
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What Other Aid Have You Applied For?: ______________________________________________
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Electric Company: _____________________________________ Account #: _________________
Propane Company: ____________________________________ Account #: _________________
Phone Company: ______________________________________ Account #: _________________
Directions To Your Home from Major Highway or Street (For Propane Delivery): ____________
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Please Fill Out Both Sides and Send Completed Application To:
Link Center Foundation
P.O. Box 2253 – Longmont, CO 80502-2253
Please List Names of People Living In Your Home, Their Relationship To You, and Their Birth Dates (include children)
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Does Anyone Living In Your Home Have Any Health Problems? If so, who has them and what are they? Please describe any special health needs or considerations.
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Is There Anything Else You
Would Like To Tell Us? ____________________________________
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Signature: _______________________________________________________________________
Date: ___________________________________________________________________________
Please Fill out Send Completed Application To:
Link Center Foundation
P.O. Box 2253 – Longmont, CO 80502-2253