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Why The B.A.E.R. Project?
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Your sponsorship will assist in improving the quality
of life for children and families in the communities
we target.
Learn more »
Type of Sponsorships
:
Charter Sponsor
National Sponsor
Regional Sponsor
Sectional Sponsor
Local Sponsor
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Your Personal Details
First Name:
* REQUIRED
Middle Initial:
Last Name:
* REQUIRED
E-Mail Address:
* REQUIRED
Total Income:
Please Select
$0 - $9,999
$10,000 ? $19,999
$20,000 - $29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
$70,000 - $79,999
$80,000 - $89,999
$90,000 - $99,999
More than $100,000
* REQUIRED
Comments:
Your Address
Street Address:
* REQUIRED
City:
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State:
Please Select
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
* REQUIRED
Zip Code:
* REQUIRED
Your Contact Information
Home Telephone Number:
* REQUIRED
Work Telephone Number:
* REQUIRED
Work Extension:
Your Username and Password
Username:
* REQUIRED
Password:
* REQUIRED
Password Confirmation:
* REQUIRED
Insurance Applicant
First Name:
* REQUIRED
Middle Initial:
Last Name:
* REQUIRED
Date of Birth:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
* REQUIRED
Gender:
Please Select
male
female
* REQUIRED
Height:
Feet:
0
1
2
3
4
5
6
7
Inches:
0
1
2
3
4
5
6
7
8
9
10
11
* REQUIRED
Weight:
* REQUIRED
Does the applicant smoke?
Yes
No
* REQUIRED
Spouse
First Name:
Middle Initial:
Last Name:
Date of Birth:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Gender:
Please Select
male
female
Height:
Feet:
0
1
2
3
4
5
6
7
Inches:
0
1
2
3
4
5
6
7
8
9
10
11
Weight:
Does the applicant's
spouse smoke?
Yes
No
Children
Quantity:
Select
1
2
3
4
5
6
7
8
9
10
Has any person to be covered
lived outside of the USA
for less than 12 months?
Yes
No
© 2004 The B.A.E.R. Project, Inc. All rights reserved.
Tel: 1-619-819-7607
Email:
info1@thebaerproject.org
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