Free System

Instructions:  Complete this form and email it to linda@BreatheEasyFoundation.org or mail it to Linda, Breathe Easy Foundation, 3651 North 100 East, Suite 300, Provo, Utah 84604. For assistance call 800-992-7027 Monday through Thursday 10-4.

Application Date _______________________

Name ___________________________________________ Age ______________

Address ____________________________________ Rent or own? _______

City, State, Zip ____________________________________________________

Daytime Phone _______________ Email _____________________________

Number in your household with serious breathing difficulties? ___________ Ages?____________________  How do you deal with these difficulties? ________________________________________________________

Number in your household suffering from the following diseases:  allergies _____ asthma _____ cancer _____ COPD _____ heart disease _____ stroke _____?  How do you deal with these difficulties? ________________________________________________________

Is anyone in your household pregnant? (Special consideration is given because air pollution can cause birth defects) __________________

Are you a past or present firefighter, member of law enforcement or the U.S. military? (They receive special consideration) ___________________

How many in your household smoke? ____________________________

How many feathery or furry indoor pets do you have? __________

Home square footage? _________  How many levels? __________

How many furnaces? ________  A/C ? ________ Swamp Cooler? __________

Household Income? (Low- to moderate-income families receive special consideration) $_____________________________________________

Signature  (must be 18 or older) ____________________________

Relation to applicant ________________

FOR OFFICE USE ONLY:

Approved By: _______________________   Date: __________________

System Received By: _________________________    Date: _________________

Helping America Breathe