Application Step 1 of 5 20% Basic Background & Contact InformationName* First Last Birth Date*When is your birthday? (mm/dd/yyyy)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email AddressPlease enter your email address. Be sure to double check spelling, as this is our primary form of contact. If an incorrect email address is entered, we will not be able to get in touch with you. Cancer Type*What type of cancer do you have?Treatment Location*Where are you being treated? (i.e. Georgetown Hospital, Sibley Memorial Hospital, Johns Hopkins, Mayo Clinic)How did you learn about us? Personal IncomeEmployment*Are you currently employed? Full-Time Part-time Retired Unemployed Job Title & Company*Where do you work and what position do you hold?Salary*Are you paid hourly or on a salary?HourlySalaryHourly Pay Rate*How much do you make per hour?Annual Salary*What is your annual salary?Hours Per Week*How many hours do you work on average per week?Supplemental Security Income*Do you receive Supplemental Security Income (SSI)?YesNoAmount of SSI*How much Supplemental Security Income (SSI) do you receive per month?Disability*Do you receive disability income?YesNoDisability Amount*How much income do you receive from disability per month?Spouse/Partner IncomeMarital Status*Please indicate your marital status below.SingleMarriedDivorcedDomestic PartnershipSeparatedWidowedSpousal Employment*Is your spouse currently employed? Full-Time Part-time Retired Unemployed Spouse/Partner Job Title & Company*Where do your spouse/partner work and what position does he/she hold?Spouse/Partner Salary*Is your spouse/partner paid hourly or on a salary?HourlySalarySpouse/Partner Hourly Pay Rate*How much does your spouse/partner make per hour?Spouse/Partner Hours Per Week*How many hours does your spouse/partner work on average per week?Spouse/Partner Annual Salary*What is your spouse/partner's annual salary?Contribution of Past Partner*What, if anything, does your past partner financially contribute?Widow's Pension*Do you receive a widow's pension or any financial compensation due to the passing of your spouse?Spouse/Partner Supplemental Security Income*Does your spouse/partner receive Supplemental Security Income (SSI)?YesNoAmount of SSI for Spouse/Partner*How much Supplemental Security Income (SSI) does your spouse/partner receive per month?Spouse/Partner Disability*Does your spouse/partner receive disability income?YesNoSpouse/Partner Disability Amount*How much income does your spouse/partner receive from disability per month?ChildrenHow many children do you have that are financially dependent upon you?Household IncomeNumber of People Living in Home*Please indicate the total number of people living in your home and their ages. Total Household Income*What is the combined income of ALL of the people in your household per year?Proof of Income*Please upload the most recent copy of your W-2 or other proof of income (i.e. Social Security Stub, Welfare Stub, Disability Stub, etc). ExpensesHousing*Do you own or rent your home?OwnRentLive with friends or familyMortgage Payment*What is your monthly mortgage payment?Monthly Rent*What is your monthly rent payment?UtilitesPlease indicate which of the following bills you are responsible for. Choose all that apply and fill out the details below. Electric Water & Sewer Cable & Internet Natural Gas Car Payment Car Insurance Home Insurance Phone Bill None Electric bill*Please indicate the approximate amount you pay for electric each month.Water & Sewer*Please indicate the approximate amount you pay for water and sewer each month.Cable & Internet*Please indicate the approximate amount you pay for cable and internet each month.Natural Gas*Please indicate the approximate amount you pay for natural gas each month.Car Payment*Please indicate the approximate amount you pay for car payment(s) each month.Car Insurance*Please indicate the approximate amount you pay for car insurance each month.Home Insurance*Please indicate the approximate amount you pay for home insurance each month.Phone bill*Please indicate the approximate amount you pay for the phone bill each month. Debt*Do you have any of the following debts? Please select all that apply. Medical Student Loan Credit Card Other None Medical Debt*Please indicate the amount of medical debt you have.Student Loan Debt*Please indicate the amount of student loan debt you have.Credit Card Debt*Please indicate the amount of credit card debt you have.Other Debt*Please indicate the amount of other debt you have. Other ConsiderationsDo you have health insurance?*YesNoIf so, what is the amount your health insurance provider will pay towards a wig, if anything?Wig Ownership*Have you ever owned a wig?YesNoWig Ownership Cont.*Do you currently own a wig?YesNoHair Length, Texture, Grade*How was your hair before you lost it? Please check all that apply. Long Shoulder-length Short Curly Wavy Straight Thick Medium-Grade Thin Hair Color*What color was your hair prior to losing it?Hair Description ContinuedPlease use this box to describe your former hair as best as possible. Are there any extenuating circumstances that you would like us to take into account?Please briefly describe what obtaining a high-quality wig means to you. AuthorizationApplication Form Waiver*By submitting this form, I authorize Lolly’s Locks to verify the information provided on this form, and by signing this form, I certify to the best of my knowledge, all information contained on this form is correct. I understand and agree that if I am selected to participate in the Lolly’s Locks program, that Lolly’s Locks may use the answers I supplied to the last field on this form for promotional purposes, including, but not limited to, content on its website. I accept What To Expect After You Submit An ApplicationOnce we receive your application, we will get in touch with you to schedule a follow-up interview. If you qualify for our program, you will be asked to provide a at least one photo of yourself and a few head measurements. You will also be asked to submit documentation of your cancer diagnosis and a prescription for a wig from your health care provider. Once a recipient submits their information and the necessary documentation, they will receive their custom wig in 2 to 3 weeks.