FR Mobility Foundation, Inc.
Grant Funding Application

Entering your name below is considered your signature. Once submitted, you acknowledge that you understand the rules and conditions of the Grant if awarded. All information provided is deemed confidential and will not be shared with any other entity except the mobility dealer for the purpose of providing assistance. You also grant us permission to use name of the recipient via photographs and/or video for print and/or electronic use of the FR Mobility Foundation, Inc. The purpose of a grant from the FR Mobility Foundation, Inc. is to assist you in completing the purchase of a new or used wheelchair accessible vehicle or other approved equipment up to $5,000.00 (30% of retail value for the conversion or other equipment). Before submitting this application, you must have secured all other funding and have a pending agreement for the purchase. Upon award, the grant will be forwarded to the mobility dealer you have directed us to in this application. Submission of this application does not guarantee approval for funds. If you have any other questions, feel free to contact us at 443-244-9925. *
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If you need to print and mail this form, please send to:
FR Mobility Foundation, Inc.
1231 Tech Court
Westminster, MD 21157