Below is our application form for prospective recipients.
If you believe you would make a good candidate for assistance, simply fill it out and we will be in touch.

CJ3 Foundation Prospective Recipient Application

Every applicant’s story and requirements are unique. To better serve you, we at the CJ3 Foundation need to better understand who you are, what your particular quality of life challenges are, etc. Please help us to help you by providing forthright and detailed responses to the following questions. We understand this may not be an easy task, but it is an important step towards improving your wellness.

"*" indicates required fields

Step 1 of 3

Are you, or have you ever been, any of the following?*
Service Date Start*
Service Date End*
Please provide applicable documentation to support your affiliation
➢ Department of Defense Form 214 (DD214) "Certificate of Release or Discharge from Active Duty."
➢ Records of employment and/or retirement from claimed Federal/State/Local/Territorial/Tribal Law Enforcement Agency, Fired Department, or other Emergency/First Responder Agency.
Max. file size: 50 MB.