Apply for Assistance Submit Application Application FormApply for Resources This form will allow you to request for specific resources based on your personalized needs. First NameLast NameGender- Select -MaleFemaleOtherOtherE-mailMobileWork PhoneDate of BirthAddress of Applicant Address Line 1Address Line 2CityStateZip CodeCountryUnited StateAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweMarital Status- Select -MarriedDivorced or SeparatedWidowedNever Married or SingleDomestic PartnershipPreferred LanguageNumber of Individuals Living in HouseholdEthnicity/Race Black or African American Hispanic or Latino Native Hawaiian or Pacific Islander American Indian/Alaska Native Asian White Prefer not to say OtherYearly Household Salary Range $0 to $25,000 $25,000 to $50,000 $50,000 to $100,000 $100,000 to $250,000 $250,000 +Education Level High school or equivalent Technical or occupational certificate Associate degree Some college coursework completed Bachelor’s degree Master’s degree Doctorate ProfessionalEmployment Status Employed Full-Time Employed Part-Time Seeking opportunities Retired Prefer not to sayHow do you plan to use your fundsAre you a Patient with SomatusPatient ID #Patient Health PlanHealth Plan Policy#Nephrologist Contact InfoPrimary Care Physician InfoOther Health ConditionsPlease answer the following questions by rating your response on a scale of 1 -5. The ratings are as follows: 1= Very UN-healthy 2= Poor health 3= Ok HEALTH  4= Good health 5 = Very healthy Rate your emotional health overall0Rate your mental health overall0Rate your physical health overall0Rate your financial health overall 0 I agree that the information herein are true and correct. I hereby agree that I am participating in the Clement Foundation grant program by my own free will and give the Clement Foundation permission to contact my insurance provider and health care provider (s) for verification of my patient status.Submit Application Form We Would Love to Hear from You Please write or call us with your questions or comments. Address 123 Fifth Avenue, New York, NY 10160, USA Contact +1 910-626-85255 contact@charity.com Keep In Touch Facebook-f Twitter Google-plus-g
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