Beneficiary Nomination Form

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FRIENDS MAKING A DIFFERENCE, INC.
A NEW JERSEY NOT FOR PROFIT CORPORATION

Friends Making A Difference is comprised of a group of friends who want to give back to our community and lend a helping hand to our neighbors in a time of need. Friends Making A Difference wants individuals and families to know they are not alone and will "get by with a little help from their friends".

The mission of Friends Making A Difference is to give back to our community and lend a helping hand to our neighbors in a time of need. If you know of someone who could benefit from the kindness of some "friends", please complete the nomination form below and submit it to us. Our nomination committee reviews all nominations and will select a benefactor for each event.

Note: All fields are required

Email *

First and Last Name of Nominee
*

Address of Nominee
*

Reason for Nomination *

Person Making Nomination First and Last Name
*

Person Making Nomination Phone Number
*

Person Making Nomination Email

Person Making Nomination Address
*

Nominee Waiver:
I authorize Friends Making A Difference to disclose my reason for nomination and verify that the reason(s) for my nomination are true and accurate. I understand that the disclosure of this information is personal and I am allowing Friends Making A Difference in the disclosure of the information contained herein to exercise all rights under HIPAA and be provided access to all Protected Health Information pursuant to HIPPA. The Health Insurance Portability and Accounting Act of 1996 42 USC 1320d and 45 CFR 160-164.
*

I Accept

I Decline

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