The Premier Gives Back Foundation
Application for Assistance

Applicants may complete and submit the below on-line form or mail the following PDF file: PGB Application to

Premier Gives Back Foundation * 3112 W Lake Mary Blvd * Lake Mary, FL 32746


A. By submitting below, I certify that: I have read and understand the Criteria and Guidelines set by The Premier Gives Back Foundation Committee. I have provided truthful, complete and accurate information on this applicant, and I have exhausted all other insurance and governmental funding sources before applying to TPGBF Committee

B. I represent and assure the Committee that, if I am granted an award, I will: Use the funds for the purpose state in this application; and promptly report in writing the TPGBF any change in the availability of Insurance and Governmental Funding sources that may affect my eligibility for funds.

I certify that, to the best of my knowledge and ability, the information included in the application is accurate as of the date submitted.

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