Chief's Choice®
Request for Assistance

CHIEF'S CHOICE® FOUNDATION, INC.
17100 WEST RYERSON ROAD
NEW BERLIN, WI 53151
TEL: 800-395-8070 - 262-796-8448
Organization or Individual making the Request: Contact:
Address: City:
State: Country: Postal Code:
Phone: Fax: E-mail:
Request Made on Behalf of:
Name: Member of:
Position: Years of Service: Supervisor:
Organization Phone: Organization Address:
Surviving Family:
Name: Relationship:
Address: City:
State: Country: Postal Code:
Phone: Fax: E-mail:
Incident:
Location: Line of Duty: Date
Description:
Comments:

I certify that the information contained in this assistance request is true and complete. I understand that a fraudulent representation or omission of any information provided is grounds for denial of assistance.

I understand that the granting of such assistance is neither a right nor entitlement and that the Chief's Choice Foundation, Inc. shall have sole discretion in determining whether to grant assistance. Chief's Choice Foundation, Inc., or its representatives shall be entitled to reasonably investigate the information provided herin for verification purposes.

17100 West Ryerson Road  |  New Berlin, WI 53151  |  TEL: 800.395.8070  |  FAX: 262.796.8449
Chief's Choice® is a registered trademark of DR TAB Products, LLC.
Site maintained by Andrew McConville at andrewmcconville.com
Copyright 2004. All Rights Reserved.