Please return completed application along with current
front and side view photographs to the address above. Photographs become the property of Fresh
Start Surgical Gifts, Inc. and cannot be returned. Applications without photographs cannot be
processed. Please call Shelley at (760) 944-2012 e-mail: firstname.lastname@example.org
for more information.
I declare under the penalty
of perjury that the foregoing is a true and accurate statement as to the
availability of any insurance or state funded reimbursements for the surgery
requested of Fresh Start Surgical Gift, Inc.